What are the guidelines for managing hypertension?

Guidelines for Managing Hypertension

The most current evidence-based approach to hypertension management includes initiating a two-drug combination therapy for most patients with BP ≥140/90 mmHg, with a preferred combination of ACE inhibitor/ARB plus a dihydropyridine calcium channel blocker, and targeting BP <140/90 mmHg for the general population and <130/80 mmHg for patients with diabetes, chronic kidney disease, or established cardiovascular disease. 1

Diagnosis and Classification

• Definition: Hypertension is defined as persistent systolic blood pressure (SBP) ≥130 mmHg or diastolic blood pressure (DBP) ≥80 mmHg 2
• Confirmation: Diagnosis should be confirmed with multiple readings at the same visit, readings from multiple visits, and ambulatory blood pressure monitoring (ABPM) to rule out white coat hypertension 1
• Basic investigations: All hypertensive patients should have:
  • Urine strip test
  • Blood electrolytes and creatinine
  • Blood glucose
  • Serum total:HDL cholesterol ratio
  • 12-lead electrocardiograph 1

Treatment Thresholds

Blood pressure levels requiring specific actions:

Blood Pressure (mmHg)	Action
≥160/100	Start drug treatment immediately [3,1]
140-159/90-99	Start drug treatment if target organ damage, cardiovascular disease, diabetes, or 10-year CVD risk ≥20% exists; otherwise, try lifestyle modifications for 3-6 months [3,1]
<140/90	Lifestyle modifications [1]

Treatment Targets

• General population: <140/90 mmHg 3, 1
• High-risk patients (diabetes, renal impairment, established cardiovascular disease): <130/80 mmHg 3, 1
• Older adults (≥65 years): Target SBP 130-139 mmHg 1

Lifestyle Modifications

Lifestyle modifications are recommended for all patients with hypertension and should include:

• DASH diet: Expected SBP reduction 3-11 mmHg 1
• Sodium reduction: Expected SBP reduction 3-6 mmHg 1
• Increased potassium intake: Expected SBP reduction 3-5 mmHg 1
• Physical activity: 30-60 minutes of moderate-intensity aerobic activity 5-7 days/week plus resistance training at least 2 days/week; Expected SBP reduction 3-8 mmHg 1
• Weight management: Expected SBP reduction 1 mmHg per kg lost 1
• Alcohol limitation: Expected SBP reduction 3-4 mmHg 1
• Smoking cessation 3, 1
• Dietary fat changes: Reducing intake of total and saturated fats, replacing saturated with monounsaturated fats (olive oil, rapeseed oil) 3

Pharmacological Treatment

First-line Options

• ACE inhibitors (e.g., lisinopril): Indicated for hypertension to lower blood pressure and reduce risk of fatal and non-fatal cardiovascular events 4
• ARBs: Alternative to ACE inhibitors with similar efficacy
• Calcium channel blockers (e.g., amlodipine): Indicated for hypertension treatment to lower blood pressure and reduce cardiovascular risk 5
• Thiazide or thiazide-like diuretics: Effective first-line agents 1, 2

Treatment Algorithm

1. Initial therapy:

   • For most patients with BP ≥140/90 mmHg: Start with a two-drug combination 1
   • Preferred combination: ACE inhibitor/ARB + dihydropyridine calcium channel blocker 1
   • Alternative combination: ACE inhibitor/ARB + thiazide-like diuretic 1

2. If BP remains uncontrolled:

   • Increase to a three-drug regimen: ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic 1

3. For resistant hypertension (BP ≥130/80 mmHg despite adherence to 3 or more agents):

   • Consider adding spironolactone, eplerenone, or other agents with different mechanisms of action 1
   • Consider referral to a hypertension specialist 1

Special Populations

• African American patients: Consider starting with a calcium channel blocker + thiazide diuretic combination 1
• Pregnant patients: Avoid ACE inhibitors and ARBs due to teratogenicity; prefer calcium channel blockers, beta-blockers, or labetalol 1
• Patients with benign prostatic hypertrophy: Alpha-blockers may be beneficial 3
• Heart failure patients: ACE inhibitors are indicated to reduce signs and symptoms of systolic heart failure 4

Monitoring and Follow-up

• Monitor BP regularly using home or clinic measurements 1
• Check serum creatinine and potassium 7-14 days after initiating ACE inhibitors, ARBs, or diuretics 1
• Follow up at least yearly once BP is controlled 1
• Consider ambulatory or home BP monitoring when clinic BP shows unusual variability, hypertension is resistant to treatment, or to diagnose "white coat" hypertension 1

Treatment Benefits

• Treating hypertension can significantly reduce the risk of:
  • Stroke by 35-40%
  • Heart attacks by 20-25%
  • Heart failure by 50% 1
• An SBP reduction of 10 mmHg decreases risk of cardiovascular events by approximately 20-30% 2

Implementation Challenges

Despite the clear benefits of BP control, only 44% of US adults with hypertension have their SBP/DBP controlled to less than 140/90 mmHg 2. Effective implementation of lifestyle measures requires knowledge, enthusiasm, patience, time spent with patients and family members, and reinforcement, ideally undertaken by well-trained health professionals such as practice or clinic nurses 3.