What are the guidelines for managing blood pressure in adults?

Blood Pressure Management Guidelines for Adults

Blood pressure should be treated to a target of less than 130/80 mmHg for most adults with hypertension, particularly those with known cardiovascular disease or 10-year ASCVD risk ≥10%. 1, 2

Classification of Blood Pressure

Category	Systolic BP	Diastolic BP
Normal	<120	<80
Elevated	120-129	<80
Stage 1 Hypertension	130-139	80-89
Stage 2 Hypertension	≥140	≥90

Diagnostic Approach

1. Proper BP Measurement:

   • Obtain at least 2 readings on at least 2 separate occasions
   • Patient seated comfortably for 5 minutes
   • Use validated devices with proper cuff size 1, 2

2. Out-of-Office BP Measurements:

   • Use ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to detect:
     • White coat hypertension (high office BP, normal out-of-office BP)
     • Masked hypertension (normal office BP, high out-of-office BP) 1, 2
   • For HBPM, target is <135/85 mmHg (equivalent to clinic BP <140/90 mmHg) 2

Treatment Targets

1. General Adult Population:

   • Target BP <130/80 mmHg for adults with confirmed hypertension and known CVD or 10-year ASCVD risk ≥10% (Class I recommendation) 1, 2
   • For adults without additional markers of increased CVD risk, a BP target of <130/80 mmHg may be reasonable (Class IIb recommendation) 1

2. Older Adults:

   • For ambulatory, community-dwelling adults ≥65 years: target BP <130/80 mmHg if tolerated 1, 2
   • For adults ≥85 years or with moderate-to-severe frailty: more lenient target (<140/90 mmHg) may be appropriate 2
   • Careful titration and close monitoring are especially important in older adults with high comorbidity burden 1

Treatment Algorithm

1. Lifestyle Modifications (for all patients):

   • Low-sodium diet
   • Regular physical activity
   • Weight loss if overweight/obese
   • Limited alcohol consumption
   • Adequate potassium intake 2

2. Pharmacological Therapy:

   • Stage 1 Hypertension (130-139/80-89 mmHg):

     • With clinical CVD or 10-year ASCVD risk ≥10%: Start drug therapy plus lifestyle changes
     • Without clinical CVD and 10-year ASCVD risk <10%: Start with lifestyle changes only 2

   • Stage 2 Hypertension (≥140/90 mmHg):

     • Start drug therapy plus lifestyle changes for all patients
     • Consider initiation with two first-line agents when BP is ≥20/10 mmHg above target 2

3. Initial Drug Selection:

   • Non-Black patients: ACE inhibitor, ARB, CCB, or thiazide-type diuretic 1, 2
   • Black patients: CCB or thiazide-type diuretic 1, 2
   • With CKD: ACE inhibitor or ARB 1, 2
   • Consider starting with combination therapy (preferably single-pill) for most patients 2

4. Treatment Intensification:

   • If BP remains above target, advance to triple therapy: ACE inhibitor/ARB + CCB + diuretic 2
   • For resistant hypertension (BP ≥130/80 mmHg on 3+ medications including a diuretic):
     • Add spironolactone or other potassium-sparing diuretic
     • Consider chlorthalidone or indapamide instead of hydrochlorothiazide
     • Add other agents with different mechanisms of action 1, 2

Special Considerations

1. Resistant Hypertension:

   • Defined as BP ≥130/80 mmHg despite adherence to 3+ antihypertensive agents from different classes at optimal doses (including a diuretic) 1
   • Risk for cardiovascular events is 2-6 fold higher than in non-resistant hypertension 1
   • Management steps:
     • Confirm diagnosis with accurate office BP measurements
     • Assess medication adherence
     • Obtain home or ambulatory BP readings
     • Address contributing lifestyle factors
     • Discontinue interfering substances (NSAIDs, stimulants, oral contraceptives)
     • Exclude secondary causes of hypertension 1, 2

2. Monitoring and Follow-up:

   • Monthly follow-up until BP control is achieved 2
   • After achieving target BP, monitor every few months 2
   • Reassess risk factors and target organ damage every 2 years 2

Common Pitfalls to Avoid

1. Inaccurate BP Measurement:

   • Improper cuff size, patient positioning, or insufficient rest time can lead to falsely elevated readings
   • Failure to average multiple readings can result in misdiagnosis 2

2. White Coat Effect:

   • Failure to recognize white coat hypertension may lead to unnecessary treatment
   • Always confirm elevated office readings with HBPM or ABPM before intensifying therapy 1, 2

3. Medication Non-adherence:

   • Up to 25% of patients don't fill initial prescriptions
   • Only 1 in 5 patients has sufficiently high adherence to achieve benefits seen in clinical trials
   • Use once-daily dosing and combination pills to improve adherence 1

4. Therapeutic Inertia:

   • Failure to intensify therapy despite uncontrolled BP
   • Implement team-based care approaches and systematic follow-up strategies 1, 2

5. Ignoring Orthostatic Hypotension:

   • Particularly important in older adults
   • Check for postural BP drops when intensifying therapy 2

Recent evidence from a 2024 randomized clinical trial demonstrated that intensive BP control to <130/80 mmHg significantly reduced cardiovascular disease and all-cause mortality in both older and younger adults with hypertension, without increasing adverse events like falls or syncope 3. This reinforces the safety and efficacy of the lower BP targets recommended in current guidelines.