What are the current guidelines for managing hypertension?

Current Hypertension Management Guidelines

According to the 2020 International Society of Hypertension (ISH) global guidelines, hypertension should be treated to a target blood pressure of <130/80 mmHg for most adults, with medication initiated immediately for high-risk patients with Grade 1 hypertension (140-159/90-99 mmHg) and all patients with Grade 2 hypertension (≥160/100 mmHg). 1

Diagnosis of Hypertension

• Hypertension is diagnosed when:

  • Office BP ≥140/90 mmHg (average of readings)
  • Home BP ≥135/85 mmHg
  • 24-hour ambulatory BP ≥130/80 mmHg 1

• Proper measurement technique:

  • Use validated automated upper arm device with appropriate cuff size
  • Patient should sit quietly for 5 minutes before measurement
  • Measure BP in both arms at first visit; use arm with higher BP if consistent difference
  • Take multiple readings (2-3) 1 minute apart 2

Treatment Approach

Lifestyle Modifications (for all patients)

• Dietary sodium restriction to <2000 mg/day (reduces SBP by 2-8 mmHg) 2
• DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy (reduces SBP by 8-14 mmHg) 2
• Regular aerobic exercise: 150 minutes/week of moderate-intensity activity (reduces SBP by 4-9 mmHg) 2
• Weight loss for overweight/obese patients (5-20 mmHg reduction per 10 kg lost) 2
• Limit alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) 2
• Smoking cessation 1

Pharmacological Treatment

When to Start Medication

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

  • Start immediately in high-risk patients (with CVD, CKD, diabetes, organ damage, or age 50-80)
  • After 3-6 months of lifestyle intervention in low-risk patients if BP remains elevated 1

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

  • Start drug treatment immediately along with lifestyle interventions 1

First-Line Medications

• Non-Black Patients:

  1. Start with low-dose ACE inhibitor or ARB
  2. Increase to full dose
  3. Add thiazide/thiazide-like diuretic
  4. Add spironolactone (or alternatives if not tolerated) 1

• Black Patients:

  1. Start with low-dose ARB plus dihydropyridine CCB or dihydropyridine CCB plus thiazide/thiazide-like diuretic
  2. Increase to full dose
  3. Add diuretic or ACE inhibitor/ARB
  4. Add spironolactone (or alternatives if not tolerated) 1

• Consider monotherapy only in low-risk Grade 1 hypertension or in patients >80 years or frail 1

Special Populations

• Diabetes: Target BP <130/80 mmHg; use ACE inhibitor or ARB as first-line therapy 2
• Chronic Kidney Disease: Target systolic BP 120-129 mmHg; use ACE inhibitor or ARB as first-line therapy 2
• Older patients (≥65 years): Target systolic BP 130-140 mmHg if tolerated; start medications at lower doses and titrate more slowly 2
• Heart Failure or CAD: Beta-blockers and ACE inhibitors are recommended as first-line therapy 2

Medication Selection Considerations

• Thiazide diuretics are superior for heart failure prevention 2
• CCBs are more effective than beta-blockers for stroke prevention 2
• Chlorthalidone (thiazide-like diuretic) has stronger evidence for cardiovascular outcomes than hydrochlorothiazide 2
• Beta-blockers are no longer first-line unless specific indications exist (e.g., CAD) 2
• Avoid combining ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury 2
• Simplify regimens with once-daily dosing and single-pill combinations when possible 1

Monitoring and Follow-up

• Target: Reduce BP by at least 20/10 mmHg; ideally to target BP 1
• Achieve BP control within 3 months 1
• Follow-up appointments:
  • Within 1 month for BP 130-139/80-89 mmHg
  • Within 2-4 weeks for BP 140-159/90-99 mmHg
  • Within 1-2 weeks for BP ≥160/100 mmHg 2
• Laboratory monitoring:
  • Check serum creatinine, eGFR, and potassium within 2-4 weeks of starting ACE inhibitors, ARBs, or diuretics
  • Annual monitoring of renal function and electrolytes for all patients on antihypertensive medications 2

Common Pitfalls to Avoid

• Inadequate BP measurement technique leading to inaccurate readings
• Failure to identify white-coat or masked hypertension
• Suboptimal medication choices based on patient demographics
• Combining ACE inhibitors with ARBs
• Inadequate follow-up monitoring of BP control and medication side effects
• Overlooking lifestyle modifications once medications are started
• Not checking for medication adherence in patients with uncontrolled BP

Remember that blood pressure reduction is the primary mechanism for reducing cardiovascular morbidity and mortality, with an SBP reduction of 10 mmHg decreasing risk of cardiovascular events by approximately 20-30% 3.