What are the guidelines for managing Hypertension (HTN)?

Guidelines for Managing Hypertension (HTN)

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, with a target of ≤ 140/85 mm Hg for most patients and ≤ 130/80 mm Hg for those with diabetes, renal impairment, or established cardiovascular disease. 1

Diagnosis and Assessment

• Blood pressure should be measured using a validated device with the patient seated, arm at heart level, with at least two measurements at each visit 1
• Ambulatory blood pressure monitoring is indicated for unusual BP variability, suspected white coat hypertension, or resistant hypertension 1
• Routine investigations should include urine testing for blood and protein, blood electrolytes and creatinine, blood glucose, serum cholesterol, and 12-lead ECG 1
• Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions 1

Thresholds for Intervention

• Urgent treatment needed for:

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

• Standard treatment thresholds:

  • Start drug treatment in all patients with sustained SBP ≥ 160 mm Hg or DBP ≥ 100 mmHg 1
  • For patients with SBP 140-159 mm Hg or DBP 90-99 mm Hg, treat if target organ damage, established cardiovascular disease, diabetes, or 10-year CVD risk ≥ 20% 1
  • For those with grade 1 (mild) hypertension without complications, evaluate lifestyle measures for up to six months before initiating drug therapy 1

Treatment Targets

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

Lifestyle Modifications

• Lifestyle measures should be recommended to all patients with hypertension and those with borderline or high-normal blood pressure 1
• Effective lifestyle interventions include:
  • Weight reduction to achieve ideal body weight 1, 2
  • Regular physical activity (30-60 minutes of aerobic exercise 4-7 days per week) 3
  • Limiting alcohol consumption (< 21 units/week for men, < 14 units/week for women) 1, 3
  • Reduced sodium intake (65-100 mmol/day) 3, 2
  • Increased consumption of fruits, vegetables, and low-fat dairy products (DASH diet) 2
  • Reduced intake of saturated fats 1, 3

Pharmacological Management

• When no compelling indications exist, initial drug selection should follow the AB/CD algorithm 1

• First-line agents include:

  • Thiazide or thiazide-like diuretics 4, 3
  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) 4, 3
  • Calcium channel blockers 4, 3
  • Beta-blockers (in those younger than 60 years) 3

• Compelling indications for specific agents:

  • Heart failure or recent myocardial infarction: beta-blockers and ACE inhibitors 3
  • Diabetes: ACE inhibitors or ARBs 3
  • Chronic kidney disease: ACE inhibitors 3
  • Left ventricular hypertrophy: ARBs (e.g., losartan) 5

Special Considerations

• Secondary hypertension should be suspected with:

  • Elevated serum creatinine or proteinuria/hematuria 1
  • Sudden onset or worsening of hypertension 1
  • Resistance to multiple drugs (≥3) 1
  • Young age (hypertension < 20 years; needing treatment < 30 years) 1
  • Electrolyte abnormalities suggesting endocrine causes 1

• Treatment in specific populations:

  • Elderly: Same targets apply, but initiate treatment more gradually 6
  • Pregnancy: Requires specialized management 1
  • Resistant hypertension: Consider secondary causes and medication adherence 1

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis 1
• Not considering white coat hypertension when office readings are elevated 1
• Inadequate dosing or inappropriate combinations of antihypertensive medications 1
• Not addressing lifestyle modifications alongside pharmacological treatment 1, 2
• Overlooking the need for lower BP targets in high-risk patients (diabetes, CKD, established CVD) 1
• Not considering secondary causes in resistant hypertension or young patients 1

Monitoring and Follow-up

• Most patients will require more than one agent to achieve BP targets 5, 7
• Regular monitoring of BP (office and home readings when possible) 1
• Annual reassessment of cardiovascular risk 1
• Monitoring for adverse effects of medications and adjusting therapy as needed 1