Additional considerations include potential compelling indications for use of an ACEI or ARB in patients with HTN and comorbidities. As this is a Not Reviewed, Not Changed recommendation, the Work Group did not systematically review evidence related to this recommendation. Based on the evidence review from the 2014 VA/DoD HTN CPG, See the VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease. Available at: https://www.healthquality.va.gov/guidelines/cd/ckd/index.asp the Work Group s confidence in the quality of the evidence is high.[136-141] Other considerations regarding this recommendation include the potential for harm (from a rare but serious adverse event) as well as reduced benefit in this patient population (i.e., reduced outcome benefit and less blood pressure reduction compared to alternative treatments). Patient values and preferences were considered to be similar. Thus, the Work Group decided to carry forward the Strong for recommendation against use of an ACEI or ARB as monotherapy in African American patients with HTN. It is appropriate to add an ACEI or ARB to a thiazide-type diuretic and/or a CCB for this population. Recommendation 25. In hypertensive patients 65 years and over, we suggest a thiazide-type diuretic for reduction in composite cardiovascular outcomes. (Weak for | Reviewed, New-added) Discussion In hypertensive patients over the age of 65, treatment with a thiazide-type diuretic compared to other treatment options has been shown to reduce a composite cardiovascular outcome which included heart failure and stroke.[142] In this same meta-analysis, beta-blockers performed worse than all other therapies and CCBs, ACEIs, and ARBs had no significant difference in the composite outcome for patients over the age of 65 compared to other therapies. It is important to note that the age of 65 is an arbitrary cut-off that was used in this single meta-analysis. 