What are the current guidelines for managing hypertension?

Current Guidelines for Hypertension Management

According to the 2020 International Society of Hypertension (ISH) Global Hypertension Practice Guidelines, hypertension is defined as persistent office blood pressure ≥140/90 mmHg, home blood pressure ≥135/85 mmHg, or 24-hour ambulatory blood pressure ≥130/80 mmHg, with treatment recommendations based on risk stratification and blood pressure levels. 1

Diagnosis and Classification

• Hypertension should be diagnosed using validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms at the first visit and using the arm with higher readings for subsequent measurements 1
• Office BP ≥140/90 mmHg indicates hypertension, particularly if confirmed by home BP ≥135/85 mmHg or 24h ambulatory BP ≥130/80 mmHg 1
• Grade 1 Hypertension: 140-159/90-99 mmHg 1
• Grade 2 Hypertension: ≥160/100 mmHg 1

Treatment Approach

Lifestyle Modifications (First-line for all patients)

• Reduce energy intake to achieve ideal body weight 1
• Limit alcohol consumption (<21 units/week for men, <14 units/week for women) 1
• Reduce sodium intake and increase potassium intake 2
• Regular physical activity (150 minutes/week of moderate aerobic exercise) 1
• Adopt healthy dietary patterns such as DASH or Mediterranean diet 1, 2
• Smoking cessation 1

Pharmacological Treatment Initiation

• For Grade 1 Hypertension (140-159/90-99 mmHg):

  • Start immediate drug treatment in high-risk patients (with CVD, CKD, diabetes, organ damage, or aged 50-80 years) 1
  • For low-moderate risk patients, begin drug therapy after 3-6 months of lifestyle intervention if BP remains elevated 1

• For Grade 2 Hypertension (≥160/100 mmHg):

  • Start immediate drug treatment alongside lifestyle interventions for all patients 1

Drug Therapy Algorithm

For Non-Black Patients:

1. Start with low-dose ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB) 1
2. Increase to full dose if needed 1
3. Add thiazide/thiazide-like diuretic 1
4. Add dihydropyridine calcium channel blocker (DHP-CCB) 1
5. Add spironolactone or, if not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

For Black Patients:

1. Start with low-dose ARB + DHP-CCB or DHP-CCB + thiazide-like diuretic 1
2. Increase to full dose if needed 1
3. Add diuretic or ACEI/ARB (whichever wasn't used initially) 1
4. Add spironolactone or, if not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Treatment Considerations

• Consider monotherapy only in low-risk grade 1 hypertension and in patients >80 years or frail 1
• Use single-pill combinations when possible to improve adherence 1
• Beta-blockers should be used when there are specific indications (e.g., coronary artery disease, heart failure, or for heart rate control) 1
• Avoid combining two RAS blockers (ACEI and ARB) 1

Blood Pressure Targets

• Target BP: <130/80 mmHg for most patients 1
• For elderly patients, individualize targets based on frailty 1
• Aim to reduce BP by at least 20/10 mmHg from baseline 1
• Achieve target BP within 3 months 1
• The 2024 ESC guidelines recommend targeting systolic BP of 120-129 mmHg in most adults, if well tolerated 1

Special Populations

• Elderly (>80 years): Consider starting with lower doses and more gradual BP reduction 1
• Diabetes: Target BP <130/80 mmHg with a treatment strategy including RAS inhibitor plus CCB and/or thiazide-like diuretic 1
• Chronic Kidney Disease: Use RAS inhibitors as first-line therapy 1
• Coronary Artery Disease: Consider beta-blockers and RAS inhibitors 1
• Black patients: Calcium channel blockers and thiazide diuretics are more effective as initial therapy than RAS blockers 1

Monitoring and Follow-up

• Monitor BP control and achieve target within 3 months 1
• Check medication adherence regularly 1
• If BP remains uncontrolled despite optimal therapy, refer to a specialist with hypertension expertise 1

Common Pitfalls to Avoid

• Inadequate BP measurement technique leading to inaccurate readings 1
• Failure to confirm office readings with home or ambulatory monitoring when appropriate 1
• Insufficient dose titration or delayed addition of complementary medications 1
• Not accounting for ethnic differences in treatment response 1
• Overlooking secondary causes of hypertension in resistant cases 3
• Neglecting lifestyle modifications while focusing solely on pharmacotherapy 4, 5

Comprehensive management of hypertension requires addressing both BP control and overall cardiovascular risk reduction, including lipid management, glucose control, and antiplatelet therapy when indicated 1, 2.