Current Hypertension Treatment Guidelines
According to the 2020 International Society of Hypertension (ISH) guidelines, hypertension treatment should follow a stepped approach with a target blood pressure of <130/80 mmHg for most patients, with individualization for elderly patients based on frailty. 1
Diagnosis and Classification
- Hypertension is defined as office BP ≥140/90 mmHg
- Diagnosis should be confirmed with:
- Office BP: Average of ≥2 readings
- Home BP monitoring: ≥135/85 mmHg
- 24-hour ambulatory BP: ≥130/80 mmHg
Initial Management Approach
Lifestyle Modifications (First-line for all patients)
All patients with hypertension should implement the following lifestyle changes:
- Weight management: 5-20 mmHg reduction per 10 kg weight loss 2
- DASH diet: Rich in fruits, vegetables, low-fat dairy; 8-14 mmHg reduction 2
- Sodium restriction: <2,300-2,400 mg/day; 2-8 mmHg reduction 2
- Physical activity: At least 150 minutes/week of moderate aerobic exercise; 4-9 mmHg reduction 2
- Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women; 2-4 mmHg reduction 2
Pharmacological Treatment
When to Start Medications
- Immediate drug therapy for:
- High-risk patients (with CVD, CKD, diabetes, or organ damage)
- BP ≥160/100 mmHg (consider two medications or single-pill combination) 2
- After 3-6 months of lifestyle intervention for low-moderate risk patients with persistent BP elevation
Medication Algorithm by Patient Population
For Non-Black Patients:
- Start with low-dose ACE inhibitor or ARB (e.g., losartan 50 mg daily) 1, 3
- Increase to full dose (e.g., losartan 100 mg daily) 3
- Add dihydropyridine calcium channel blocker (e.g., amlodipine) 1, 4
- Add thiazide/thiazide-like diuretic (e.g., chlorthalidone 12.5-25 mg) 1, 5
- Add spironolactone or, if not tolerated, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1
For Black Patients:
- Start with low-dose ARB + DHP-CCB or DHP-CCB + thiazide-like diuretic 1, 2
- Increase to full dose
- Add diuretic or ACE inhibitor/ARB (if not already included)
- Add spironolactone or, if not tolerated, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1
Special Populations
Diabetes
- First-line: ACE inhibitor or ARB 2
- Target BP: <130/80 mmHg 2
- For nephropathy in Type 2 diabetes: Start losartan 50 mg daily, increase to 100 mg daily based on BP response 3
Left Ventricular Hypertrophy
- Start with losartan 50 mg daily
- Add hydrochlorothiazide 12.5 mg daily and/or increase losartan to 100 mg daily 3
Hepatic Impairment
- For mild-to-moderate impairment: Start with reduced dose (e.g., losartan 25 mg daily) 3
- Avoid in severe hepatic impairment
Monitoring and Follow-up
- Monitor BP control with target to achieve within 3 months 1
- Check serum creatinine/eGFR and potassium within 3 months of starting ACE inhibitors, ARBs, or diuretics, then annually 2
- Follow-up within 1 month for Stage 1 hypertension with drug therapy and Stage 2 hypertension 2
- Once BP control is achieved, follow-up every 3-6 months 2
Treatment Goals
- Reduce BP by at least 20/10 mmHg 1
- Target BP <130/80 mmHg for most patients 1, 2
- Individualize targets for elderly patients based on frailty 1
Common Pitfalls to Avoid
- Avoid ACE inhibitor + ARB combinations due to increased adverse effects without additional benefit 2
- Don't delay pharmacotherapy in high-risk patients or those with BP ≥160/100 mmHg 2
- Don't neglect lifestyle modifications even after starting medications 6
- Don't overlook medication adherence when BP control is not achieved 1
- Don't use a "one-size-fits-all" approach - consider ethnicity, comorbidities, and age in treatment decisions 1, 2
The most recent evidence emphasizes that effective BP control significantly reduces both microvascular and macrovascular complications, particularly in patients with diabetes 2, and that a comprehensive approach combining appropriate pharmacotherapy with sustained lifestyle modifications yields the best outcomes 6.