What are the current guidelines for managing hypertension?

Current Guidelines for Managing Hypertension

The 2020 International Society of Hypertension guidelines recommend a comprehensive approach to hypertension management with blood pressure targets of <130/80 mmHg for most patients, using combination therapy as initial treatment for most hypertensive patients. 1

Diagnosis and Classification

• 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 1
• Grade 1 Hypertension: 140-159/90-99 mmHg 1
• Grade 2 Hypertension: ≥160/100 mmHg 1
• Diagnosis should use validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms at the first visit 1

Treatment Approach

Lifestyle Modifications

• Weight management: Maintain healthy body mass index (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 2
• Physical activity: 150+ minutes/week of moderate aerobic exercise or 75 minutes of vigorous exercise weekly, plus resistance training 2-3 times/week 2
• Dietary approaches: Follow Mediterranean or DASH diets 1, 2
• Sodium restriction: Limit to approximately 2 g per day 2
• Alcohol limitation: <14 drinks/week for men and <9 drinks/week for women 2
• Smoking cessation 2

Pharmacological Treatment

Initial Treatment Strategy

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

  • High-risk patients: Start immediate drug treatment 1
  • 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

Medication Selection

• First-line medications include ACE inhibitors, ARBs, dihydropyridine calcium channel blockers (CCBs), and thiazide/thiazide-like diuretics 2, 3, 4
• For most patients with confirmed hypertension, combination BP-lowering treatment is recommended as initial therapy 2
• Preferred combinations are a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide-like diuretic 2
• Fixed-dose single-pill combinations improve adherence 2
• For non-Black patients: Start with low-dose ACE inhibitor or ARB, and increase to full dose if needed 1
• For Black patients: Start with low-dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 1

Blood Pressure Targets

• General target: <130/80 mmHg for most patients 1, 2
• For patients with diabetes: <130/80 mmHg (<140/80 mmHg in elderly patients) 5
• For elderly patients (>80 years): Individualize targets based on frailty 1
• For patients with chronic kidney disease: <140/90 mmHg 2
• For patients with stroke or TIA history: <140/90 mmHg 2

Special Populations

Diabetes

• BP should be lowered if ≥140/90 mm Hg and treated to a target <130/80 mm Hg (<140/80 in elderly patients) 5
• Treatment strategy should include an RAS inhibitor (and a CCB and/or thiazide-like diuretic) 5
• Include statin therapy based on cardiovascular risk profile 5

Chronic Kidney Disease

• Use RAS inhibitors as first-line therapy 1
• Target BP <140/90 mmHg 2

Elderly Patients

• Consider starting with lower doses and more gradual BP reduction 1
• For patients ≥85 years or with moderate-to-severe frailty, monotherapy may be considered instead of combination therapy 2

Coronary Artery Disease

• Consider beta-blockers and RAS inhibitors 1
• Beta-blockers should be used when there are specific indications such as coronary artery disease, heart failure, or for heart rate control 1

Implementation and Follow-up

• Monitor BP control and aim to achieve target within 3 months 1, 2
• Regular follow-up (monthly) until target BP is achieved 2
• BP-lowering drug treatment should be maintained lifelong, even beyond age 85, if well tolerated 2
• Check medication adherence regularly 1

Common Pitfalls and Considerations

• Avoid combining two RAS blockers (ACEI and ARB) 1, 2
• Many patients believe not adding salt to food equals a low-salt diet, but education about checking food labels and hidden sodium sources is essential 2
• Failure to adhere to low-sodium diets is a significant cause of resistant hypertension 6
• For resistant hypertension, mineralocorticoid receptor antagonists like spironolactone can be effective add-on agents 7, 6
• Consider secondary causes of hypertension in patients with resistant hypertension 6