What are the treatment guidelines for hypertension?

From the Guidelines

The treatment guidelines for hypertension in adults should be based on the most recent and highest quality evidence, which recommends initiating pharmacological therapy in adults with a systolic blood pressure of 140 mmHg or higher or a diastolic blood pressure of 90 mmHg or higher, with a target blood pressure of less than 140/90 mmHg, as stated in the World Health Organization guideline executive summary 1.

Key Considerations for Treatment

• The guidelines recommend lifestyle modification counseling before initiating pharmacological therapy.
• The choice of monotherapy or dual therapy, treatment with single pill combination medications, and use of treatment algorithms for hypertension management should be guided by the quality of the underlying evidence, patient values, resource considerations, and cost-effectiveness.
• The goal of the guideline is to facilitate standard approaches to pharmacological treatment and management of hypertension, which, if widely implemented, will increase the hypertension control rate worldwide.

Monitoring and Follow-up

• Patients with hypertension should be seen as often as needed until adequate blood pressure control is obtained and then seen as necessary.
• Assessment may include multiple measurements in clinical settings or ambulatory or home monitoring.

Pharmacological Treatment Options

• Initial drug therapy may be with any drug class currently indicated for the treatment of hypertension, with ACE inhibitors, β-blockers, and diuretics being preferred agents for initial therapy due to their proven benefits in reducing cardiovascular disease events 1.
• Effective pharmacologic options include antihypertensive medications, such as thiazide-type diuretics, ACEIs, ARBs, calcium-channel blockers, and β-blockers, each with their potential adverse effects.

Importance of Patient Education and Compliance

• Informing the patient of the risk of hypertension and the benefit of effective treatment, providing clear instructions, and tailoring the treatment regimen to the patient's lifestyle and needs can improve compliance with treatment 1.
• Simplifying treatment, involving the patient's partner or family, and using self-measurement of blood pressure at home and behavioral strategies can also enhance adherence to the treatment plan.

From the Research

Guidelines for Treatment of Hypertension

The treatment of hypertension involves a combination of lifestyle modifications and antihypertensive therapies. According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) 2, the guidelines recommend that most patients receive first-line therapy with thiazide diuretics. However, the majority of patients will require 2 or more antihypertensive agents to achieve adequate blood pressure control.

First-Line Treatment Options

• Thiazide diuretics are recommended as the first-line treatment for hypertension 2, 3
• Beta-blockers, calcium channel blockers, ACE inhibitors, and alpha-blockers may be used as alternative first-line treatments or in combination with thiazide diuretics 3, 4
• The selection of additional antihypertensive therapies should be based on the presence of concomitant cardiovascular and metabolic conditions as well as patient-specific factors such as race 2

Combination Therapy

• Combining beta-blockers and ACE inhibitors may provide effective blood pressure lowering and improved cardiovascular outcomes 5
• The combination of these agents into a single pill may allow a greater proportion of patients to rapidly achieve treatment targets 5
• Synergies among antihypertensive classes may improve blood pressure control, and combination therapy may also permit the use of smaller doses of each medication and reduce the risk of dose-related adverse effects 2

Comparative Effectiveness of Antihypertensive Medications

• A systematic review and multiple treatments meta-analysis found that there was little or no difference between commonly used blood pressure lowering medications for primary prevention of cardiovascular disease 4
• Beta-blockers (atenolol) were found to be inferior to angiotensin receptor blockers (ARB) for total mortality, and ACE-inhibitors were found to be inferior to calcium-channel blockers (CCB) for stroke risk 4
• Diuretics were found to reduce the risk of myocardial infarction compared to beta-blockers, and lowered the risk of heart failure compared to CCB, beta-blockers, and alpha-blockers 4