Recommendations for Antihypertensive Agents
COR	LOE	Recommendations
I	A	Antihypertensive therapy should be administered to patients with hypertension and PAD to reduce the risk of MI, stroke, heart failure, and cardiovascular death.158–162
See Online Data Supplements 17 and 18.		Treatment of elevated blood pressure is indicated to lower the risk of cardiovascular events.162 Target blood pressure and selection of antihypertensive therapy should be consistent with current published guidelines for hypertension management. Concerns have been raised that antihypertensive therapy may reduce limb perfusion. However, multiple studies have demonstrated that blood pressure treatment, including the use of beta blockers, does not worsen claudication symptoms or impair functional status in patients with PAD.163–165 There is no evidence that one class of antihypertensive medication or strategy is superior for blood pressure lowering in PAD.158,166,167 An updated multisocietal guideline on the management of high blood pressure is anticipated in 2017.
IIa	A	The use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers can be effective to reduce the risk of cardiovascular ischemic events in patients with PAD.161,168,169
See Online Data Supplement 17.		The effect of ramipril versus placebo on cardiovascular events was studied in high-risk patients free of heart failure in the HOPE (Heart Outcomes Prevention Evaluation) trial.168,169 Patients were normotensive on average at the time of enrollment. In a subgroup of 4051 patients with PAD, ramipril reduced the risk of MI, stroke, or vascular death by 25%, similar to the efficacy in the entire study population.168,169 The efficacy was similar in patients with PAD with symptomatic disease and asymptomatic low ABI.168 ONTARGET (Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial) compared telmisartan, ramipril, and combination therapy in patients with cardiovascular disease, including PAD, and/or diabetes mellitus.161 All 3 treatments had similar cardiovascular event rates with higher rates of adverse events (including hypotension, syncope, and renal failure) in the combination-therapy group. The efficacy of telmisartan was similar in the subgroup of 3468 patients with PAD, which supports the use of angiotensin-receptor blockers as an alternative to angiotensin-converting enzyme inhibitors.161 The effect of angiotensin-receptor blockers in asymptomatic PAD has not been studied.