What are the guidelines for managing hypertension?

Hypertension Management Guidelines

The management of hypertension requires a combination of lifestyle modifications and pharmacological therapy, with a target blood pressure of <130/80 mmHg for most adults to reduce morbidity and mortality from cardiovascular events 1.

Diagnosis and Evaluation

Blood Pressure Measurement

• Patient should be seated with arm at heart level
• Use properly calibrated device with appropriate cuff size
• Take at least two measurements at each visit
• Consider ambulatory blood pressure monitoring (ABPM) for:
  • Unusual BP variability
  • Resistant hypertension (≥3 drugs)
  • Suspected white coat hypertension
  • Symptoms suggesting hypotension 2

Initial Evaluation

• Routine investigations for all hypertensive patients:
  • Urine test for blood and protein
  • Blood electrolytes and creatinine
  • Blood glucose
  • Serum total:HDL cholesterol ratio
  • 12-lead ECG 2

Treatment Thresholds

• Immediate drug treatment for:

  • Sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg 2, 1
  • Patients with diabetes or evidence of organ damage 1

• Consider drug treatment for:

  • Sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg with:
    • Target organ damage
    • Established cardiovascular disease
    • Diabetes
    • 10-year cardiovascular disease risk ≥20% 2

Blood Pressure Targets

• General target: <130/80 mmHg for most adults 1
• Higher risk populations (diabetes, renal impairment, established cardiovascular disease): ≤130/80 mmHg 1
• Minimum acceptable control (audit standard): <150/90 mmHg 2

Non-Pharmacological Management

All patients with hypertension should receive advice on lifestyle modifications:

• Weight reduction to achieve ideal body weight
• Physical activity: Regular dynamic exercise (e.g., brisk walking)
• Dietary modifications:
  • DASH diet rich in fruits, vegetables, and low-fat dairy products 1, 3
  • Sodium restriction to 5g/day 1
  • Increased consumption of fruits and vegetables 2
  • Reduced intake of saturated fat 2
  • Increased intake of oily fish 2
• Alcohol limitation: <21 units/week for men, <14 units/week for women 2
• Smoking cessation 2, 1

These lifestyle modifications can reduce blood pressure significantly and may reduce the need for medication or allow lower doses 4.

Pharmacological Management

First-Line Therapy

• For most patients without compelling indications:
  • Low-dose thiazide diuretics or β-blockers 2
  • ACE inhibitors, ARBs, or calcium channel blockers 1, 4

Special Populations

• Patients with diabetes and albuminuria/proteinuria:
  • ACE inhibitors preferred 1
• Black patients:
  • ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 1
• Patients with stage 2 hypertension (≥160/100 mmHg):
  • Consider combination therapy with ACE inhibitor/ARB and calcium channel blocker or diuretic 1

Treatment Escalation

1. Start with monotherapy for mild hypertension
2. If BP not controlled, use two-drug combination
3. If BP still not controlled, progress to three-drug combination: RAS blocker + CCB + thiazide diuretic 1
4. For resistant hypertension, add spironolactone as fourth-line agent 1

Important Considerations and Cautions

• Avoid combining ACE inhibitors with ARBs - increases adverse effects without additional benefit 1

• Monitor for orthostatic hypotension, especially in older patients 1

• Contraindications:

  • Avoid ACE inhibitors/ARBs in women of childbearing potential (teratogenic) 1
  • Discontinue ACE inhibitors/ARBs when pregnancy is detected 5

• Follow-up:

  • Within 2-4 weeks after starting or changing medications
  • Check serum creatinine and potassium 7-14 days after initiating ACE inhibitors/ARBs 1

Indications for Specialist Referral

• Urgent treatment needed:
  • Malignant hypertension
  • Severe hypertension (>220/120 mmHg)
  • Impending complications (TIA, left ventricular failure)
• Suspected secondary hypertension
• Resistant hypertension (≥3 drugs)
• Young age (<30 years needing treatment)
• Pregnancy 2

Effective implementation of these guidelines requires a systematic approach, patient education, and regular monitoring to ensure optimal blood pressure control and reduction of cardiovascular risk.