Hypertension Management Guidelines
For effective hypertension management, blood pressure targets should be ≤140/85 mmHg for most patients, while patients with diabetes, renal impairment, or established cardiovascular disease should aim for a lower target of ≤130/80 mmHg. 1, 2
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 to determine blood pressure thresholds 1
- Ambulatory blood pressure monitoring is indicated when clinic blood pressure shows unusual variability, hypertension is resistant to drug treatment, symptoms suggest hypotension, or to diagnose white coat hypertension 1
- Routine investigations should include urine strip test for blood and protein, blood electrolytes and creatinine, blood glucose, serum total:HDL cholesterol ratio, and 12-lead ECG 1
- Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions 1
Thresholds for Intervention
- Drug treatment should be started in all patients with sustained systolic blood pressures ≥160 mmHg or sustained diastolic blood pressures ≥100 mmHg despite non-pharmacological measures 3, 1
- Drug treatment is also indicated in patients with sustained systolic blood pressures 140-159 mmHg or diastolic blood pressures 90-99 mmHg if target organ damage is present, established cardiovascular disease, diabetes, or 10-year cardiovascular disease risk ≥20% 3, 1
- Urgent treatment is needed for accelerated hypertension, particularly severe hypertension (>220/120 mmHg), or impending complications 3
Treatment Targets
- For most patients, the target blood pressure is ≤140/85 mmHg 1, 2
- For patients with diabetes, renal impairment, or established cardiovascular disease, the target blood pressure is ≤130/80 mmHg 1, 2
- When using ambulatory blood pressure readings, targets should be approximately 10/5 mmHg 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, 2
- Effective lifestyle interventions include:
- Weight reduction to achieve ideal body weight via reduced fat and total calorie intake 1
- Regular physical activity (predominantly dynamic exercise like brisk walking) 1
- Limiting alcohol consumption to <21 units per week for men and <14 units per week for women 1
- Reduced sodium intake and elimination of excessively salty foods 1, 4
- Increased consumption of fruits, vegetables, and low-fat dairy products (DASH diet) 5, 4
- Smoking cessation and reduced intake of saturated fat 1
Pharmacological Management
- First-line agents include thiazide or thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and calcium channel blockers 2, 6
- For most patients with confirmed hypertension, combination therapy is often recommended as many will require more than one drug to achieve blood pressure goals 2, 7, 8
- Preferred combinations include a renin-angiotensin system blocker with either a calcium channel blocker or diuretic 2
- Medications like amlodipine and lisinopril have been shown to lower blood pressure and reduce the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions 7, 8
Special Considerations
- Secondary hypertension should be suspected with elevated serum creatinine, proteinuria/hematuria, sudden onset or worsening of hypertension, resistance to multiple drugs, young age, or electrolyte abnormalities 3, 1
- Specialist referral is indicated for urgent treatment needs, investigation of potential underlying causes, therapeutic problems or failures, and special circumstances like unusually variable blood pressure or pregnancy 3
- For elderly patients (≥80 years), treatment should be maintained if well tolerated 2
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, 9
- Overlooking the need for lower BP targets in high-risk patients (diabetes, CKD, established CVD) 1, 2
- Not considering secondary causes in resistant hypertension or young patients 1