What are the guidelines for treating high blood pressure (hypertension)?

Guidelines for Treating High Blood Pressure (Hypertension)

For most adults with hypertension, the recommended target blood pressure is ≤140/85 mmHg, while patients with diabetes, renal impairment, or established cardiovascular disease should aim for a lower target of ≤130/80 mmHg. 1, 2

Diagnosis and Classification

• 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 2
• Hypertension is classified as:
  • Normal: <120/80 mmHg 1
  • Prehypertension/Elevated: 130-139/80-89 mmHg 1
  • Stage 1: 140-159/90-99 mmHg 1
  • Stage 2: ≥160/100 mmHg 1
• Ambulatory or home blood pressure monitoring should be considered for suspected white coat hypertension, with expected values approximately 10/5 mmHg lower than office readings 1, 2

Treatment Thresholds

• Urgent treatment is needed for BP ≥180/110 mmHg 1
• For BP 140-159/90-99 mmHg, treatment decisions should consider:
  • Presence of target organ damage
  • Established cardiovascular disease
  • Diabetes
  • 10-year cardiovascular disease risk ≥20% 1, 2
• All patients with confirmed BP ≥140/90 mmHg should receive prompt lifestyle measures and pharmacological treatment 1

Lifestyle Modifications

• Lifestyle modifications are recommended for all patients with elevated blood pressure and should complement pharmacological therapy 1, 3
• Effective lifestyle interventions include:
  • Regular physical activity: 150 minutes/week of moderate-intensity aerobic exercise complemented with resistance training 2-3 times/week 1, 4
  • Weight reduction: aim for BMI 20-25 kg/m² and healthy waist circumference (<94 cm in men, <80 cm in women) 1, 5
  • Dietary changes: adopt Mediterranean or DASH diet rich in fruits, vegetables, and low in saturated fat 1, 3
  • Sodium restriction: reduce to <5g salt per day 1, 6
  • Alcohol moderation: limit to 100g/week of pure alcohol or less 1
  • Smoking cessation 1

Pharmacological Management

• First-line drug therapy includes:

  • Thiazide or thiazide-like diuretics
  • Angiotensin-converting enzyme (ACE) inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Calcium channel blockers (CCBs) 1, 6

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 1

• Preferred combinations include a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or diuretic 1

• Fixed-dose single-pill combinations are recommended to improve adherence 1

• If BP is not controlled with a two-drug combination, a three-drug combination is recommended (RAS blocker + CCB + thiazide/thiazide-like diuretic) 1

• Beta-blockers should be combined with other classes when there are compelling indications (angina, post-myocardial infarction, heart failure) 1

• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1

Special Populations

• Patients with diabetes, renal impairment, or established cardiovascular disease should aim for a lower target of ≤130/80 mmHg 1, 2
• For elderly patients (≥80 years), treatment should be maintained if well tolerated 1
• In resistant hypertension, consider secondary causes and medication adherence before adding additional agents 2, 5

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis 2
• Not considering white coat hypertension when office readings are elevated 2
• Inadequate dosing or inappropriate combinations of antihypertensive medications 2
• Not addressing lifestyle modifications alongside pharmacological treatment 2, 3
• Overlooking the need for lower BP targets in high-risk patients 2
• Not considering secondary causes in resistant hypertension or young patients 2

Monitoring and Follow-up

• Regular BP monitoring is necessary, with home readings when possible 2
• Annual reassessment of cardiovascular risk is recommended 2
• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence 1