What are the latest guidelines for hypertension (HTN) management?

Latest Guidelines for Hypertension Management

The latest guidelines recommend initiating pharmacological therapy if BP ≥160/100 mmHg (severe hypertension) or BP 140-159/90-99 mmHg with cardiovascular disease, target organ damage, or 10-year cardiovascular risk ≥20%, with a general target of <140/90 mmHg for most patients and <130/80 mmHg for those with diabetes, chronic kidney disease, or established cardiovascular disease. 1

Diagnosis and Classification

Hypertension is classified as:

• Normal: <120/80 mmHg
• Elevated: 120-129/<80 mmHg
• Stage 1: 130-139/80-89 mmHg
• Stage 2: ≥140/90 mmHg 1

Lifestyle Modifications

Lifestyle modifications are recommended for all patients with elevated blood pressure or hypertension:

• Weight reduction: 5-20 mmHg reduction in systolic BP per 10 kg weight loss; target BMI 18.5-24.9 kg/m² 1
• DASH diet: 8-14 mmHg reduction in systolic BP 1
• Sodium restriction: 2-8 mmHg reduction with intake <2,300 mg/day 1
• Physical activity: 4-9 mmHg reduction with 30 minutes of aerobic activity most days 1
• Alcohol moderation: 2-4 mmHg reduction; limit to ≤2 drinks/day for men or ≤1 drink/day for women 1

Pharmacological Treatment

Initial Treatment Strategy

• Stage 1 hypertension with lower risk: Start with monotherapy
• Stage 2 hypertension or high-risk patients: Start with a two-drug combination 1

Recommended Drug Combinations

• ACE inhibitor + dihydropyridine calcium channel blocker
• ACE inhibitor + thiazide diuretic
• ARB + dihydropyridine calcium channel blocker
• ARB + thiazide diuretic 1

Population-Specific Recommendations

• Black patients: Start with calcium channel blocker or thiazide-like diuretic 1
• Non-Black patients: Start with ACE inhibitor or ARB 1
• Diabetes with nephropathy: ARB preferred 1
• Left ventricular hypertrophy: Consider ARB (not applicable to Black patients) 1

Medication Selection Considerations

ACE inhibitors like lisinopril are indicated for hypertension treatment and have been shown to reduce the risk of fatal and non-fatal cardiovascular events 2. Similarly, calcium channel blockers like amlodipine are effective for blood pressure reduction and cardiovascular risk reduction 3.

Treatment Algorithm

1. Initial Assessment:

   • Confirm hypertension diagnosis with accurate BP measurements
   • Assess cardiovascular risk factors and target organ damage
   • Rule out secondary causes of hypertension

2. Treatment Initiation:

   • For all patients: Implement lifestyle modifications
   • For BP ≥160/100 mmHg: Start pharmacological therapy immediately
   • For BP 140-159/90-99 mmHg with high risk: Start pharmacological therapy
   • For Stage 1 hypertension with lower risk: Start with monotherapy
   • For Stage 2 hypertension: Start with two-drug combination

3. Drug Selection Based on Patient Characteristics:

   • Black patients: Calcium channel blocker or thiazide-like diuretic
   • Non-Black patients: ACE inhibitor or ARB
   • Diabetes/CKD: ACE inhibitor or ARB (target <130/80 mmHg)
   • Established CVD: ACE inhibitor or ARB (target <130/80 mmHg)

4. Follow-up and Titration:

   • Monthly follow-up until BP is controlled
   • Check serum creatinine, eGFR, and potassium within 3 months of starting therapy
   • Once controlled, follow-up every 3-6 months
   • Monitor serum creatinine/eGFR and potassium at least annually 1

Resistant Hypertension Management

If BP remains uncontrolled on three drugs including a diuretic, consider adding a mineralocorticoid receptor antagonist (spironolactone) 1.

Common Pitfalls to Avoid

• Inappropriate combinations: Avoid ACE inhibitor + ARB and beta-blocker + diuretic combinations due to increased risk of adverse effects 1
• Inadequate follow-up: Ensure monthly follow-up until BP is controlled 1
• Insufficient dose titration: Start with standard doses and titrate to full doses as needed 1
• Overlooking secondary causes: Consider secondary hypertension in patients with sudden onset/worsening hypertension, resistance to multi-drug regimen, young age, or kidney abnormalities 1
• Ignoring ambulatory/home BP readings: When using these measurements, targets should be approximately 10/5 mmHg lower than office BP equivalents 1