What are the guidelines for managing Hypertension (HTN)?

Guidelines for Hypertension Management

Drug treatment should be started in all patients with sustained systolic blood pressures ≥ 160 mm Hg or sustained diastolic blood pressures ≥ 100 mmHg despite non-pharmacological measures, and in patients with sustained systolic blood pressures 140-159 mm Hg or diastolic blood pressures 90-99 mm Hg if target organ damage is present, cardiovascular disease, diabetes, or a 10-year cardiovascular disease risk ≥ 20%. 1

Diagnosis and Classification

• Hypertension diagnosis requires 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 2

• Classification of hypertension:

  Classification	Blood Pressure
  Normal BP	<120/80 mmHg
  Elevated BP (Prehypertension)	120-129/<80 mmHg
  Stage 1 Hypertension	130-139/80-89 mmHg
  Stage 2 Hypertension	≥140/90 mmHg
  Hypertensive Crisis	>180/120 mmHg

Treatment Thresholds

• Start drug treatment when:

  • Sustained systolic BP ≥ 160 mmHg or diastolic BP ≥ 100 mmHg despite lifestyle modifications
  • Sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg with target organ damage, established cardiovascular disease, diabetes, or 10-year cardiovascular risk ≥ 20% 1

• Urgent treatment needed for:

  • Accelerated hypertension (severe hypertension with grade III-IV retinopathy)
  • Particularly severe hypertension (> 220/120 mmHg)
  • Impending complications (e.g., TIA, left ventricular failure) 1

Blood Pressure Targets

• For most patients: ≤ 140 mmHg systolic and ≤ 85 mmHg diastolic 1
• For patients with diabetes, renal impairment, or established cardiovascular disease: ≤ 130/80 mmHg 1, 2
• When using ambulatory or home BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents 1

Lifestyle Modifications

Lifestyle modifications should be recommended to all patients with hypertension and those with borderline or high-normal blood pressure 1:

• Weight management: Maintain healthy BMI (18.5-24.9 kg/m²); 5-20 mmHg reduction for every 10 kg weight loss 2
• DASH diet: Emphasize fruits, vegetables, low-fat dairy products; 3-11 mmHg reduction 2
• Sodium restriction: < 2.4 grams per day; 2-8 mmHg reduction 2
• Physical activity: 30-45 minutes of aerobic exercise 4-5 days per week; 3-8 mmHg reduction 1, 2
• Alcohol limitation: ≤ 2 drinks/day for men, ≤ 1 drink/day for women; 3-4 mmHg reduction 2
• Smoking cessation 1
• Stress management in selected individuals 1

Pharmacological Treatment

Initial Drug Selection

When no special considerations apply, follow this approach:

1. For 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 2

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

   • Initiate with two-drug combination therapy plus lifestyle modifications 2
   • Preferred combinations: ACE inhibitor/ARB + calcium channel blocker or ACE inhibitor/ARB + thiazide-like diuretic 2

Special Considerations for Drug Selection

• Compelling indications for specific drug classes exist 1:
  • Heart failure: ACE inhibitors, beta-blockers
  • Post-myocardial infarction: ACE inhibitors, beta-blockers
  • Diabetes or chronic kidney disease: ACE inhibitors or ARBs 2
  • African American patients: Consider calcium channel blocker + thiazide diuretic combination 2
  • Pregnancy: Avoid ACE inhibitors and ARBs; prefer calcium channel blockers, beta-blockers, or labetalol 2

Monitoring and Follow-up

• Evaluate patients within 1 month of initial diagnosis and treatment initiation
• Monitor BP every 2-4 weeks until goal is achieved, then every 3-6 months 2
• Assess for medication adherence, side effects, and lifestyle modification compliance

Benefits of Treatment

Treating hypertension significantly reduces:

• Stroke risk by 35-40%
• Heart attack risk by 20-25%
• Heart failure risk by 50% 2

Common Pitfalls to Avoid

• Clinical inertia (failure to intensify treatment when BP remains uncontrolled)
• Inadequate diuretic therapy
• Ignoring medication adherence issues
• Overlooking interfering substances (NSAIDs, stimulants, oral contraceptives)
• Inappropriate combinations (e.g., combining two RAS blockers) 2
• White coat hypertension (consider ambulatory or home BP monitoring) 1

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