What are the guidelines for classifying and treating hypertension?

Hypertension Classification and Treatment Guidelines

The current guidelines define hypertension as blood pressure ≥140/90 mmHg, with treatment recommendations based on cardiovascular risk assessment, though American guidelines use a lower threshold of ≥130/80 mmHg. 1, 2

Classification of Hypertension

According to the European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guidelines:

Category	Systolic BP (mmHg)	Diastolic BP (mmHg)
Normal	120-129	80-84
High normal	130-139	85-89
Grade 1 hypertension	140-159	90-99
Grade 2 hypertension	160-179	100-109
Grade 3 hypertension	≥180	≥110

Note: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines define hypertension at the lower threshold of ≥130/80 mmHg. 1

Risk Assessment

Hypertension management decisions should be based on:

1. Blood pressure levels
2. Total cardiovascular risk assessment including:
   • Age, sex, smoking status
   • Presence of other cardiovascular risk factors
   • Presence of hypertension-mediated organ damage (HMOD)
   • Presence of established cardiovascular disease
   • Presence of comorbidities (diabetes, kidney disease)

Risk categories:

• Low risk
• Moderate risk
• High risk
• Very high risk

Diagnostic Evaluation

• Office BP measurement: Multiple readings on separate occasions
• Out-of-office BP measurement: Home BP monitoring or ambulatory BP monitoring
• Basic laboratory investigations:
  • Hemoglobin, fasting glucose
  • Serum lipids
  • Serum potassium, sodium, creatinine, eGFR
  • Urinalysis with microalbuminuria
  • 12-lead ECG

Treatment Initiation Thresholds

Treatment should be initiated based on BP levels and cardiovascular risk:

1. Grade 2-3 hypertension (≥160/100 mmHg): Immediate drug treatment for all patients
2. Grade 1 hypertension (140-159/90-99 mmHg):
   • Immediate drug treatment for high/very high-risk patients
   • Drug treatment after several weeks of lifestyle changes for low/moderate-risk patients
3. High normal BP (130-139/85-89 mmHg):
   • Consider drug treatment only for very high-risk patients with established cardiovascular disease

Treatment Approach

1. Lifestyle Modifications (for all patients)

• Salt restriction (<5g/day)
• DASH or Mediterranean diet
• Regular physical activity (150+ minutes/week)
• Weight reduction (target BMI 20-25 kg/m²)
• Alcohol limitation (<14 drinks/week for men, <9 drinks/week for women)
• Smoking cessation

2. Pharmacological Treatment

First-line medications:

• ACE inhibitors (e.g., lisinopril)
• Angiotensin receptor blockers (ARBs)
• Calcium channel blockers
• Thiazide or thiazide-like diuretics

Treatment strategy:

• Initial therapy: Consider single-pill combination of two drugs (except in frail elderly or low-risk grade 1 hypertension)
• Preferred combinations: ACE inhibitor/ARB + calcium channel blocker or diuretic
• Three-drug therapy if needed: ACE inhibitor/ARB + calcium channel blocker + diuretic
• Resistant hypertension: Add spironolactone or other diuretic, beta-blocker, or alpha-blocker

3. Treatment Targets

• General target: <140/90 mmHg for all patients
• If treatment is well-tolerated:
  • Target 130/80 mmHg or lower for most patients <65 years
  • Target SBP 130-139 mmHg for patients ≥65 years

Special Populations

Elderly Patients

• More gradual BP lowering
• Monitor for orthostatic hypotension
• Target SBP 130-139 mmHg if tolerated for those ≥65 years

Diabetes

• Target BP <130/80 mmHg if tolerated
• ACE inhibitor or ARB preferred as part of treatment regimen

Chronic Kidney Disease

• Target BP <140/90 mmHg
• Consider lower targets if proteinuria present
• ACE inhibitor or ARB preferred

Pregnancy

• Target BP 110-129/65-79 mmHg
• Avoid ACE inhibitors and ARBs (contraindicated)

Monitoring and Follow-up

• Follow-up within 2-4 weeks after starting or changing medications
• Monitor serum creatinine, eGFR, and potassium at baseline and at least annually
• Annual follow-up for stable patients with controlled BP

Common Pitfalls

• Failing to screen for secondary hypertension in young adults (<40 years)
• Overly aggressive BP lowering in frail elderly
• Not monitoring renal function when using ACE inhibitors or ARBs
• Using ACE inhibitors and ARBs simultaneously (increases risk of hyperkalemia and kidney injury)
• Neglecting lifestyle modifications as a cornerstone of treatment

By following these guidelines, clinicians can effectively classify and manage hypertension to reduce cardiovascular morbidity and mortality.