What are the guidelines for managing hypertension?

Hypertension Management Guidelines

The most current hypertension management approach recommends classifying blood pressure as normal (<120/80 mmHg), elevated (120-129/<80 mmHg), stage 1 (130-139/80-89 mmHg), or stage 2 (≥140/90 mmHg), with treatment strategies tailored to severity and cardiovascular risk. 1

Diagnosis and Assessment

• Confirm hypertension using standardized measurement techniques:

  • Validated automated upper arm cuff with appropriate size
  • Patient seated with arm at heart level
  • After 5 minutes of quiet rest
  • At least two measurements per visit
  • Consider ambulatory or home BP monitoring to rule out white coat effect 2, 1

• Initial evaluation should include:

  • Urine testing for blood and protein
  • Blood electrolytes and creatinine
  • Blood glucose
  • Serum total:HDL cholesterol ratio
  • 12-lead ECG 2

Treatment Approach

Lifestyle Modifications

All patients with elevated BP or hypertension should receive lifestyle modification recommendations:

• DASH diet (rich in fruits, vegetables, low-fat dairy): 3-11 mmHg reduction 1, 3
• Sodium reduction: 3-6 mmHg reduction 1
• Weight reduction to ideal body weight: 1 mmHg per kg lost 1
• Regular physical activity (primarily dynamic exercise): 3-8 mmHg reduction 2, 1
• Limited alcohol consumption (<21 units/week for men, <14 units/week for women): 3-4 mmHg reduction 2, 1
• Increased potassium intake: 3-5 mmHg reduction 1, 4

Pharmacological Treatment

1. Stage 1 Hypertension (130-139/80-89 mmHg):

   • With 10-year ASCVD risk ≥10%: Start with a single agent (thiazide diuretic, ACE inhibitor, ARB, or CCB) 1
   • Implement lifestyle modifications alongside medication

2. Stage 2 Hypertension (≥140/90 mmHg):

   • Initiate two-drug combination therapy with:
     • ACE inhibitor/ARB + calcium channel blocker, OR
     • ACE inhibitor/ARB + thiazide-like diuretic 1

3. Treatment Targets:

   • General population: <130/80 mmHg 1
   • Elderly (fit): <130/80 mmHg (more gradual reduction in frail elderly) 1
   • Diabetes or CKD: <130/80 mmHg 1

Special Populations

• African American patients: Start with calcium channel blocker + thiazide diuretic 1
• Elderly patients: Start with lower doses and titrate more slowly 1
• Pregnant patients: Avoid ACE inhibitors and ARBs; prefer calcium channel blockers, beta-blockers, or labetalol 1
• Diabetes/CKD patients: Prefer ACE inhibitors or ARBs 1
• Women of childbearing potential: Avoid ACE inhibitors and ARBs 1

Monitoring and Follow-up

• Evaluate within 1 month of treatment initiation
• Monitor BP every 2-4 weeks until goal is achieved
• Once at goal, monitor every 3-6 months
• Allow at least 4 weeks to observe full response to medication changes 1

Common Pitfalls to Avoid

1. Clinical inertia: Failing to intensify treatment when BP remains uncontrolled
2. Inadequate diuretic therapy: Often needed for resistant hypertension
3. Overlooking medication adherence issues
4. Ignoring interfering substances: NSAIDs, stimulants, oral contraceptives
5. Inappropriate combinations: Combining two RAS blockers (ACE inhibitor + ARB) 1
6. Overlooking white coat hypertension: Consider ambulatory monitoring when clinic BP shows unusual variability 2

Indications for Specialist Referral

• Urgent treatment needed (hypertensive crisis: >180/120 mmHg)
• Suspected secondary causes of hypertension
• Treatment failures or therapeutic problems
• Special circumstances: highly variable BP, suspected white coat hypertension, pregnancy 2

Remember that effective hypertension management reduces cardiovascular morbidity and mortality, with every 10 mmHg reduction in systolic BP decreasing CVD events by approximately 20-30% 5.