What are the current recommendations for managing hypertension according to recent guidelines?

Current Recommendations for Managing Hypertension According to Recent Guidelines

According to the 2020 International Society of Hypertension (ISH) global hypertension practice guidelines, hypertension is defined as office BP ≥140/90 mmHg, with treatment recommendations stratified by risk factors and comorbidities to reduce morbidity and mortality. 1

Diagnosis of Hypertension

• Office BP Measurement: Use validated automated upper arm cuff device with appropriate cuff size

  • BP ≥140/90 mmHg is classified as hypertension
  • Confirm with home BP (≥135/85 mmHg) or 24-hour ambulatory BP (≥130/80 mmHg) monitoring 1

• Initial Assessment:

  • Measure BP in both arms at first visit; use arm with higher reading if consistent difference
  • Take multiple readings (average of ≥2 readings)
  • Screen for secondary causes and target organ damage

Treatment Approach

Non-Pharmacological Interventions

• Lifestyle modifications are foundational for all patients:
  • Sodium restriction: Limit to <5g salt/day (2g sodium) 1, 2
  • Potassium-rich diet: Increase intake of fruits, vegetables, and other potassium sources (except in patients with renal failure or taking potassium-sparing diuretics) 1
  • DASH diet: Emphasize fruits, vegetables, whole grains, lean proteins 2
  • Physical activity: At least 150 minutes of moderate-intensity aerobic activity weekly 3
  • Weight management: Achieve and maintain healthy BMI 1, 4
  • Alcohol limitation: ≤2 standard drinks/day for men, ≤1 for women 3
  • Smoking cessation 4

Pharmacological Treatment

When to Start Medication

• Grade 1 Hypertension (140-159/90-99 mmHg):

  • Start drug treatment immediately in high-risk patients (CVD, CKD, diabetes, organ damage, or aged 50-80 years)
  • For others, try lifestyle interventions for 3-6 months before starting medication 1

• Grade 2 Hypertension (≥160/100 mmHg):

  • Start drug treatment immediately along with lifestyle interventions 1

Medication Algorithm

For Non-Black Patients:

1. Start with low-dose ACE inhibitor/ARB (e.g., lisinopril 10mg) 1, 5
2. If not at target, increase to full dose
3. Add dihydropyridine calcium channel blocker (DHP-CCB)
4. Add thiazide-like diuretic (preferably chlorthalidone over hydrochlorothiazide) 1, 3, 6
5. For resistant hypertension, add spironolactone or alternative (amiloride, doxazosin, eplerenone, clonidine, or beta-blocker) 1, 3

For Black Patients:

1. Start with low-dose ARB + DHP-CCB or DHP-CCB + thiazide-like diuretic 1
2. Increase to full dose
3. Add diuretic or ACE inhibitor/ARB (if not already included)
4. For resistant hypertension, add spironolactone or alternative 1

Blood Pressure Targets

• General target: <130/80 mmHg for most adults 3, 2
• Elderly patients: Target should be individualized based on frailty
  • For patients <80 years: <140/90 mmHg
  • For patients ≥80 years: 140-145/90 mmHg if tolerated 3
• Minimum goal: Reduce BP by at least 20/10 mmHg 1

Monitoring and Follow-up

• Achieve target BP within 3 months 1
• Monitor electrolytes and renal function after starting medications, particularly with ACE inhibitors, ARBs, or diuretics
• Simplify regimen with once-daily dosing and single-pill combinations when possible 1
• Consider home BP monitoring to improve adherence and assess treatment efficacy 3

Special Considerations

• Elderly patients: Start at lower doses and titrate more gradually 3
• Chronic kidney disease: Consider loop diuretics instead of thiazides if creatinine clearance <30 mL/min 3
• Resistant hypertension: Add spironolactone as fourth-line agent after ensuring optimal three-drug therapy 3
• Avoid excessive lowering of diastolic BP below 70-75 mmHg in elderly patients with coronary heart disease 3

Common Pitfalls to Avoid

• Inadequate BP measurement: Ensure proper technique and equipment
• Clinical inertia: Don't delay intensifying therapy when BP remains uncontrolled
• Ignoring adherence issues: Assess and address medication adherence regularly
• Overlooking secondary causes: Consider screening in resistant hypertension
• Inappropriate combinations: Avoid combining ACE inhibitors with ARBs or direct renin inhibitors like aliskiren 7

Following these evidence-based recommendations can significantly reduce cardiovascular morbidity and mortality associated with hypertension.