Latest Guidelines for Managing Systemic Hypertension
The most current guidelines recommend a blood pressure target of <130/80 mmHg for patients with cardiovascular disease, diabetes, or chronic kidney disease, and <140/90 mmHg for the general population, with treatment decisions based on comprehensive cardiovascular risk assessment. 1
Diagnosis and Classification
Hypertension is defined as:
- Normal: <120/80 mmHg
- Elevated: 120-129/<80 mmHg
- Stage 1: 130-139/80-89 mmHg
- Stage 2: ≥140/90 mmHg
Accurate measurement is critical:
- Use validated devices
- Patient should be seated quietly for 5 minutes
- Support arm at heart level
- Use appropriate cuff size
- Take multiple readings (at least 2) with 1-2 minute intervals
Treatment Thresholds
- Initiate pharmacological therapy if:
Treatment Targets
- General population: <140/90 mmHg 2, 1
- Patients with diabetes, chronic kidney disease, or established cardiovascular disease: <130/80 mmHg 1
- When using home or ambulatory BP monitoring, targets should be approximately 10/5 mmHg lower than office BP equivalents 1
Non-Pharmacological Interventions
Lifestyle modifications are recommended for all patients with elevated blood pressure or hypertension:
| Modification | Approximate SBP Reduction | Recommendation |
|---|---|---|
| Weight loss | 5-20 mmHg per 10 kg | Target BMI 18.5-24.9 kg/m² |
| DASH diet | 8-14 mmHg | Rich in fruits, vegetables, whole grains, low-fat dairy |
| Sodium reduction | 2-8 mmHg | <2,300 mg/day, ideally <1,500 mg/day |
| Physical activity | 4-9 mmHg | 30 min aerobic activity most days (90-150 min/week) |
| Alcohol moderation | 2-4 mmHg | ≤2 drinks/day for men, ≤1 drink/day for women |
Pharmacological Treatment Algorithm
Initial Therapy
- For most patients with Stage 1 hypertension and lower risk: Start with monotherapy
- For Stage 2 hypertension (≥160/100 mmHg) or high-risk patients: Start with two-drug combination 1
First-line Medications
- Non-Black patients: ACE inhibitor or ARB, calcium channel blocker (CCB), or thiazide/thiazide-like diuretic 1
- Black patients: CCB or thiazide/thiazide-like diuretic 1
- Patients with specific comorbidities:
Combination Therapy
Preferred combinations:
- ACE inhibitor or ARB + CCB
- ACE inhibitor or ARB + thiazide diuretic
- CCB + thiazide diuretic 1
Avoid combinations:
- ACE inhibitor + ARB (increased risk of adverse effects without additional benefit)
- Beta-blocker + diuretic (increased risk of diabetes) 2
Resistant Hypertension
- For patients not achieving target BP on three medications including a diuretic:
Special Populations
Older Adults
- Treatment thresholds and targets are similar to the general population
- Start with lower doses and titrate more gradually
- Monitor for orthostatic hypotension
Diabetes
- Initiate treatment at BP ≥140/90 mmHg
- Target BP <130/80 mmHg
- Preferred initial therapy: ACE inhibitor or ARB 1
Chronic Kidney Disease
- Target BP <130/80 mmHg
- Preferred initial therapy: ACE inhibitor or ARB 1
Follow-up and Monitoring
- Monthly follow-up until BP is controlled 1
- Check serum creatinine, eGFR, and potassium within 3 months of starting therapy 1
- Once controlled, follow-up every 3-6 months 1
- Monitor serum creatinine/eGFR and potassium at least annually 1
Adjunctive Therapies
- Aspirin: Consider 75 mg daily in patients ≥50 years with controlled BP (<150/90 mmHg) and high cardiovascular risk 2
- Statins: Consider in patients with 10-year cardiovascular risk ≥20% 2
By following these evidence-based guidelines, clinicians can effectively manage hypertension to reduce cardiovascular morbidity and mortality, which remains the primary goal of treatment.