Latest Hypertension Management Guidelines
The latest hypertension guidelines recommend a blood pressure target of <130/80 mmHg for most adults, with pharmacological treatment initiated at ≥130/80 mmHg for those with high cardiovascular risk and at ≥140/90 mmHg for lower-risk individuals. 1
Blood Pressure Classification
According to the 2021 WHO and 2017 ACC/AHA guidelines, blood pressure should be classified as:
| Category | Systolic BP | Diastolic BP |
|---|---|---|
| Normal BP | <120 mmHg | <80 mmHg |
| Elevated BP | 120-129 mmHg | <80 mmHg |
| Stage 1 Hypertension | 130-139 mmHg | 80-89 mmHg |
| Stage 2 Hypertension | ≥140 mmHg | ≥90 mmHg |
Diagnostic Approach
- Multiple office BP measurements are the gold standard for diagnosis
- Home blood pressure monitoring (HBPM) and ambulatory blood pressure monitoring (ABPM) are recommended to confirm diagnosis and monitor treatment
- ABPM is considered the most accurate method for diagnosis, with daytime average BP ≥135/85 mmHg defined as hypertension 1
Treatment Thresholds
- For adults with high cardiovascular risk (established CVD, diabetes, chronic kidney disease, or 10-year CVD risk ≥10%): Initiate pharmacological treatment at BP ≥130/80 mmHg 1
- For adults with low cardiovascular risk: Initiate pharmacological treatment at BP ≥140/90 mmHg 1
- For adults aged ≥65 years: Treatment decisions should consider overall health status and frailty 1
Treatment Targets
- General population: <130/80 mmHg 1
- Older adults (≥65 years): SBP <130 mmHg if tolerated 1, 2
- Patients with diabetes or CKD: <130/80 mmHg 1, 2
First-Line Pharmacological Treatment
The latest guidelines recommend using any of these four medication classes as first-line therapy:
- Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide)
- Angiotensin-converting enzyme inhibitors (ACEIs)
- Angiotensin receptor blockers (ARBs)
- Calcium channel blockers (CCBs) 1, 3
Treatment Algorithm
- Initial therapy: Start with a single agent at low dose from one of the four first-line classes
- If BP goal not achieved within 2-4 weeks: Increase dose or add a second agent from a different class
- If BP goal not achieved with two drugs: Add a third agent (typically a combination of ACEI/ARB + CCB + thiazide diuretic)
- For resistant hypertension: Consider adding a mineralocorticoid receptor antagonist (e.g., spironolactone) 1, 3
Special Considerations
- Black patients: Initial therapy should include a CCB or thiazide diuretic 1
- Patients with diabetes: ACEI or ARB preferred as first-line therapy 2
- Patients with CKD: ACEI or ARB preferred as first-line therapy 1, 2
- Avoid combining:
- ACEI + ARB (increases adverse effects without significant BP benefit)
- Beta-blockers + thiazides (increases risk of new-onset diabetes) 2
Lifestyle Modifications
All patients with elevated BP or hypertension should implement these lifestyle changes:
- Dietary changes:
- Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week 2, 5
- Weight management: Maintain healthy BMI (18.5-24.9 kg/m²) 6, 5
- Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women 7, 6
- Smoking cessation 7
Follow-up Monitoring
- Reassess BP within 2-4 weeks after medication changes
- Monitor serum potassium and renal function, especially with ACEI/ARB therapy
- Once BP goal is achieved, follow-up every 3-6 months 1, 2
Common Pitfalls to Avoid
- White coat hypertension: Confirm elevated office readings with HBPM or ABPM
- Therapeutic inertia: Don't delay intensification of treatment when BP remains above target
- Medication nonadherence: Use once-daily dosing and single-pill combinations when possible
- Inadequate lifestyle counseling: Lifestyle modifications should continue even after starting medications 1
The latest evidence clearly demonstrates that achieving lower BP targets significantly reduces cardiovascular morbidity and mortality, making aggressive but careful BP control a priority in hypertension management.