What are the latest guidelines for managing hypertension?

Latest Hypertension Guidelines (2020)

The 2020 International Society of Hypertension (ISH) global guidelines define hypertension as repeated office blood pressure ≥140/90 mmHg, with immediate drug treatment recommended for Grade 2 hypertension (≥160/100 mmHg) and high-risk Grade 1 hypertension patients. 1

Diagnosis of Hypertension

Hypertension is diagnosed when:

• Office BP ≥140/90 mmHg (repeated measurements)
• Confirmed by home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg

Proper BP Measurement Technique

• Use validated automated upper arm cuff device with appropriate cuff size
• At first visit, measure BP in both arms; use arm with higher BP if consistent difference
• For initial assessment, use average of multiple readings

Treatment Algorithm

Step 1: Risk Assessment and Initial Management

• Grade 1 Hypertension (140-159/90-99 mmHg):

  • Start lifestyle interventions for all patients
  • Start immediate drug treatment in high-risk patients (CVD, CKD, diabetes, organ damage, or aged 50-80 years)
  • For low-moderate risk patients: 3-6 months of lifestyle intervention before medication

• Grade 2 Hypertension (≥160/100 mmHg):

  • Start lifestyle interventions
  • Start drug treatment immediately

Step 2: Drug Therapy Based on Race

For Non-Black Patients:

1. Start with low dose ACEI/ARB (e.g., lisinopril)
2. Increase to full dose
3. Add thiazide/thiazide-like diuretic
4. Add spironolactone (or alternatives if not tolerated: amiloride, doxazosin, eplerenone, clonidine, beta-blocker)

For Black Patients:

1. Start with low dose ARB
2. Add DHP-CCB (e.g., amlodipine) or DHP-CCB + thiazide/thiazide-like diuretic
3. Increase to full dose
4. Add diuretic or ACEI/ARB
5. Add spironolactone (or alternatives if not tolerated)

Special Considerations

• Consider monotherapy in low-risk Grade 1 hypertension and elderly patients >80 years or frail
• Simplify regimen with once-daily dosing and single-pill combinations
• For elderly patients, individualize target based on frailty

Blood Pressure Targets

• General target: <130/80 mmHg 1
• Minimum goal: Reduce BP by at least 20/10 mmHg
• Elderly: Individualize based on frailty
• Achieve target within 3 months

Lifestyle Modifications

All guidelines consistently recommend these core lifestyle interventions 2:

• Weight reduction (for overweight/obese patients)
• DASH diet (may be the most effective non-pharmacological intervention)
• Sodium restriction (<2g/day)
• Regular physical activity (150 minutes/week of moderate activity)
• Alcohol limitation (≤2 drinks/day for men, ≤1 drink/day for women)

Monitoring and Follow-up

• Monitor BP control to achieve target within 3 months
• Check medication adherence regularly
• Consider additional tests for suspected organ damage or secondary hypertension
• Refer to hypertension specialist if BP remains uncontrolled despite optimal therapy

Important Caveats

1. Pregnancy warning: ACEIs/ARBs must be discontinued immediately when pregnancy is detected as they can cause fetal injury and death 3

2. Medication effectiveness by race: Some antihypertensive drugs have smaller effects in black patients as monotherapy 4

3. Comprehensive approach: Hypertension management should be part of comprehensive cardiovascular risk management, including lipid control, diabetes management, smoking cessation, and limited sodium intake 3, 4

4. Multiple medications often needed: Many patients will require more than one drug to achieve BP goals 3, 4

5. Adherence challenges: Despite proven benefits of BP control, adherence remains a significant barrier to achieving targets