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To assess which antihypertensive drug classes are the most preferred in patients newly initiated on treatment in Swedish primary care.The Swedish Primary Care Cardiovascular Database (SPCCD) comprises almost 75000 patients attending primary care with a diagnosis of hypertension in two geographically defined rural and urban regions in Sweden. All primary care physicians and patients at the 48 primary care centres are included and data are automatically extracted, minimizing potential selection bias due to voluntary participation. The current observational cohort study included patients aged > = 30 years with previously untreated hypertension and a first prescription of an antihypertensive drug during 2006–2007. Preferred drug class was analysed according to sex, age and concurrent diseases.We identified 5225 patients (mean age 61.4 years, 55% women) with first time prescribed antihypertensive treatment. Around one in ten patients had diabetes, with a lower prevalence in women than men (8.0 vs 11.1%, P < 0.01). The most preferred drug class was angiotensin converting enzyme inhibitors (36.2%), although substantially less common in women than in men (30.5 vs 43.1%; P < 0.001). However, diuretics were more common in women (32.4 vs. 19.7%; P < 0.001), while we observed no differences between women and men in the prescriptions of angiotensin receptor blockers (3.6 vs 4.3%), beta blockers (21.8 vs 19.5%), calcium channel blockers (7.0 vs 8.0%), fixed combination therapy (1.6 vs 2.2%), and those with more than one antihypertensive drug prescription (3.1 vs 3.2%). Furthermore, there were less diabetic women than men with a prescription of an angiotensin converting enzyme inhibitor (60.2 vs 73.9%, < 0.01).In conclusion, angiotensin converting enzyme inhibitors is the most preferred initial antihypertensive drug class in primary care, indicating a high concordance with contemporary guidelines.