What are the guidelines for managing hypertension?

Guidelines for Managing Hypertension

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 patients with diabetes, renal impairment, or established cardiovascular disease. 1, 2

Diagnosis and Blood Pressure Measurement

• 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
• Ambulatory blood pressure monitoring is indicated for unusual BP variability, suspected white coat hypertension, or resistant hypertension 1, 2
• When using ambulatory or home blood pressure readings, mean daytime pressures should be approximately 10/5 mm Hg lower than office BP equivalents for both thresholds and targets 1, 2

Thresholds for Intervention

• Urgent treatment is needed for:

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

• Standard treatment thresholds:

  • Start drug treatment in all patients with sustained SBP ≥ 160 mm Hg or DBP ≥ 100 mmHg despite lifestyle measures 1
  • For patients with SBP 140-159 mm Hg or DBP 90-99 mm Hg, treat if target organ damage is present, or there is evidence of established cardiovascular disease or diabetes, or if there is a 10-year cardiovascular disease risk of ≥ 20% 1, 2

Treatment Targets

• For most patients, target blood pressure is ≤ 140 mm Hg systolic and ≤ 85 mm Hg diastolic 1, 2
• For patients with diabetes, renal impairment, or established cardiovascular disease, target blood pressure is ≤ 130/80 mm Hg 1, 2, 3
• The Hypertension Optimal Treatment (HOT) trial showed that optimal blood pressure for reduction of major cardiovascular events was 139/83 mm Hg 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:
  • Salt restriction to 5-6 g per day 1
  • Moderation of alcohol consumption (≤ 20-30 g ethanol/day for men, ≤ 10-20 g ethanol/day for women) 1
  • Increased consumption of vegetables, fruits, and low-fat dairy products 1, 4
  • Weight reduction to achieve BMI of 25 kg/m² and waist circumference < 102 cm for men and < 88 cm for women 1, 4
  • Regular exercise (at least 30 min of moderate dynamic exercise on 5-7 days per week) 1, 4
  • Smoking cessation 1, 4

Pharmacological Management

• First-line drug therapy options include:

  • Thiazide or thiazide-like diuretics
  • Angiotensin-converting enzyme (ACE) inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Calcium channel blockers (CCBs)
  • Beta-blockers (in those younger than 60 years) 1, 2, 5

• When no compelling indications exist, initial drug selection should follow the AB/CD algorithm 1, 2

• Most patients will require more than one agent to achieve target blood pressure 5, 6

• A combination of two first-line agents may be considered for initial treatment if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target 6

Special Considerations

• Secondary hypertension should be suspected with:

  • Elevated serum creatinine or proteinuria/hematuria
  • Sudden onset or worsening of hypertension
  • Resistance to multiple drugs
  • Young age (any hypertension < 20 years; needing treatment < 30 years)
  • Electrolyte abnormalities suggesting endocrine causes 1, 2, 7

• Resistant hypertension (uncontrolled BP despite ≥3 antihypertensive agents):

  • Rule out pseudoresistance, secondary causes, and intake of interfering substances
  • Optimize the antihypertensive regimen with complementary mechanisms of action
  • Consider adding a mineralocorticoid receptor antagonist as a fourth drug 7

Monitoring and Follow-up

• Regular monitoring of BP (office and home readings when possible) is necessary 2, 3
• After treatment initiation, patients should be seen frequently (every 1-3 months) until BP is controlled 8
• Annual reassessment of cardiovascular risk is recommended 2, 3

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, 7
• 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, 2
• Not considering secondary causes in resistant hypertension or young patients 1, 7