Guidelines for Managing Hypertension
Diagnosis and Classification
For most adults with hypertension, the target blood pressure should be ≤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
- 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, 2
- Hypertension is classified as: Normal: <120/80 mmHg, Elevated: 130-139/80-89 mmHg, Stage 1: 140-159/90-99 mmHg, Stage 2: ≥160/100 mmHg 2
- Ambulatory blood pressure monitoring is indicated for unusual BP variability, suspected white coat hypertension, or resistant hypertension 1
- When using ambulatory BP readings, targets should be approximately 10/5 mm Hg lower than office BP equivalents 1
Treatment Thresholds
- 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 3, 1
- Drug treatment is also indicated for patients with sustained systolic blood pressures 140-159 mm Hg or diastolic blood pressures 90-99 mm Hg 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, severe hypertension (>220/120 mmHg), or impending complications (e.g., transient ischemic attack, left ventricular failure) 3, 2
Lifestyle Modifications
- Lifestyle measures should be recommended to all patients with hypertension and those with borderline or high-normal blood pressure 1, 4
- Effective lifestyle interventions include:
- Weight reduction to achieve an ideal body weight 3, 5
- Regular physical activity (30-60 minutes, 4-7 days per week) 1, 5
- Limiting alcohol consumption (<21 units/week for men, <14 units/week for women) 3, 1
- Reduced sodium intake and elimination of excessively salty foods 3, 5
- Increased consumption of fruits, vegetables, and low-fat dairy products 1, 5
Pharmacological Management
- When no compelling indications exist, initial drug selection should follow a structured algorithm 1, 6
- First-line agents include:
- For most patients with confirmed hypertension, combination therapy is often needed to achieve target blood pressure 2, 6
- Preferred combinations include a renin-angiotensin system (RAS) blocker with either a dihydropyridine calcium channel blocker or diuretic 2, 6
Special Populations
- For patients with diabetes, renal impairment, or established cardiovascular disease, the target blood pressure is ≤130/80 mmHg 3, 2
- In elderly patients (≥80 years), treatment should be maintained if well tolerated 2, 4
- Secondary hypertension should be suspected with elevated serum creatinine, proteinuria/hematuria, sudden onset or worsening of hypertension, resistance to multiple drugs, young age (<30 years), or electrolyte abnormalities 3, 1
Monitoring and Follow-up
- Regular monitoring of BP (office and home readings when possible) is necessary 1, 2
- Annual reassessment of cardiovascular risk is recommended 1, 2
- Most patients will require more than one agent to achieve target blood pressure 3, 6
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, 5
- Overlooking the need for lower BP targets in high-risk patients (diabetes, CKD, established CVD) 3, 1
- Not considering secondary causes in resistant hypertension or young patients 3, 1