Hypertension Classification and Management Parameters
Hypertension is classified as: Normal BP: <120/80 mmHg, Elevated BP (Prehypertension): 120-129/<80 mmHg, Stage 1 Hypertension: 130-139/80-89 mmHg, Stage 2 Hypertension: ≥140/90 mmHg, and Hypertensive Crisis: >180/120 mmHg. 1
Blood Pressure Classification
| Classification | Systolic BP (mmHg) | Diastolic BP (mmHg) |
|---|---|---|
| Normal | <120 | <80 |
| Elevated (Prehypertension) | 120-129 | <80 |
| Stage 1 Hypertension | 130-139 | 80-89 |
| Stage 2 Hypertension | ≥140 | ≥90 |
| Hypertensive Crisis | >180 | >120 |
Blood Pressure Measurement Technique
- Follow standardized technique for accurate measurement 1:
- Use properly calibrated equipment with appropriate cuff size
- Patient should be seated quietly for at least 5 minutes
- Record two or more readings at each visit 2
- Assess blood pressure on several occasions before confirming diagnosis 2
- Measure standing blood pressure in elderly patients and those with diabetes to detect orthostatic hypotension 2
Treatment Thresholds and Targets
When to Initiate Treatment:
- Immediate treatment for:
Blood Pressure Targets:
- General population: <140/90 mmHg 1
- High-risk patients (diabetes, kidney disease, established cardiovascular disease): <130/80 mmHg 1
- Elderly patients: <140/80 mmHg 2, 1
- Heart failure patients: <130/80 mmHg but >120/70 mmHg 2
Treatment Approach
1. Lifestyle Modifications
Lifestyle interventions are first-line therapy with the following approximate BP reductions 1, 3:
| Intervention | Approximate Systolic BP Reduction |
|---|---|
| DASH diet | 3-11 mmHg |
| Weight loss | 1 mmHg per kg lost |
| Sodium reduction | 3-6 mmHg |
| Physical activity (150 min/week) | 3-8 mmHg |
| Alcohol moderation | 3-4 mmHg |
| Potassium increase | 3-5 mmHg |
Key lifestyle recommendations include:
- Reduce total energy intake to achieve ideal body weight 2
- Limit alcohol (<21 units/week for men, <14 units/week for women) 2
- Reduce salt intake (eliminate table salt) 2
- Regular physical exercise 2, 1
- Smoking cessation 2, 1
2. Pharmacological Therapy
First-line medications include:
- ACE inhibitors or ARBs
- Calcium channel blockers (especially dihydropyridines)
- Thiazide or thiazide-like diuretics 1, 3
Population-specific considerations:
- Non-black patients: Start with low-dose ACE inhibitor/ARB 1
- Black patients: Low-dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 1
- Most patients will require at least two antihypertensive medications 1
- For resistant hypertension (not achieving target on 3 drugs including a diuretic), consider adding spironolactone 1
3. Special Populations
- Chronic Kidney Disease: Target BP <130/80 mmHg, use RAS inhibitors as first-line 2
- Heart Failure: Target BP <130/80 mmHg but >120/70 mmHg, use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 2, 1
- Diabetes: Target BP <130/80 mmHg, use RAS inhibitor + CCB and/or thiazide-like diuretic 2, 1
- Elderly: Start with lower doses and titrate slowly, target <140/80 mmHg 1
- Pregnancy: Avoid ACE inhibitors and ARBs; use methyldopa, labetalol, or nifedipine 1
Monitoring and Follow-up
- Follow-up every 2-4 weeks until BP goal is achieved 1
- Then every 3-6 months for maintenance 1
- Monitor electrolytes, creatinine, and eGFR, particularly with ACE inhibitors or ARBs 1
- Allow at least four weeks to observe full response to medication changes 1
- Assess medication adherence and side effects at each visit 1
Common Pitfalls to Avoid
- Inadequate BP measurement technique leading to misdiagnosis
- Failing to check for orthostatic hypotension in elderly patients
- Not allowing sufficient time between medication adjustments
- Overlooking potential secondary causes of hypertension, especially in young adults (<40 years) 1
- Neglecting lifestyle modifications while focusing solely on pharmacotherapy
- Inadequate follow-up and monitoring of treatment response