What are the guidelines for managing hypertension?

Hypertension Management Guidelines

The optimal management of hypertension requires a combination of lifestyle modifications and pharmacological therapy, with a target blood pressure of ≤140/85 mmHg for most adults and ≤130/80 mmHg for patients with diabetes, renal impairment, or established cardiovascular disease to reduce morbidity and mortality. 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 accurate blood pressure thresholds 1
• Ambulatory blood pressure monitoring is indicated when clinic blood pressure shows unusual variability, when hypertension is resistant to treatment (three or more drugs), when symptoms suggest hypotension, or to diagnose white coat hypertension 3, 1
• Routine investigations for hypertensive patients should include:
  • Urine strip test for blood and protein
  • Blood electrolytes and creatinine
  • Blood glucose
  • Serum total:HDL cholesterol ratio
  • 12-lead electrocardiograph 3, 1
• Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions 1, 4

Treatment Thresholds

• Urgent treatment is needed for accelerated hypertension, severe hypertension (≥180/110 mmHg), or impending complications 1, 2
• Drug treatment should be initiated in all patients with sustained SBP ≥160 mmHg or DBP ≥100 mmHg 1
• For patients with SBP 140-159 mmHg or DBP 90-99 mmHg, treatment is indicated if target organ damage, established cardiovascular disease, diabetes, or 10-year CVD risk ≥20% is present 1, 2

Treatment Targets

• The optimal blood pressure for reduction of major cardiovascular events is 139/83 mmHg 3
• 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, 4
• When using ambulatory BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents 1

Lifestyle Modifications

• Lifestyle modifications should be recommended to all hypertensive patients and those with borderline or high-normal blood pressure 1, 5
• Effective lifestyle interventions include:
  • Weight reduction to achieve an ideal body weight via reduced fat and total calorie intake 3, 5
  • Regular physical activity (30-60 minutes of predominantly dynamic exercise 4-7 days per week) 3, 6
  • Limiting alcohol consumption to <21 units per week for men and <14 units per week for women 3, 6
  • Reduced sodium intake (less than 100 mmol/day for prevention, 65-100 mmol/day for treatment) 3, 6
  • Increased consumption of fruits, vegetables, and low-fat dairy products 3, 7
  • Smoking cessation 5, 6

Pharmacological Management

• First-line drug therapy for hypertension includes:
  • Thiazide or thiazide-like diuretics
  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)
  • Calcium channel blockers (CCBs)
  • Beta-blockers (in those younger than 60 years) 1, 4
• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is often needed to achieve target blood pressure 2, 4
• Preferred combinations include a renin-angiotensin system (RAS) blocker (such as lisinopril) with either a dihydropyridine CCB (such as amlodipine) or diuretic 2, 8, 9
• Lowering blood pressure reduces the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions 8, 9

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 1, 10
• Resistant hypertension (uncontrolled BP despite three or more medications) requires evaluation for secondary causes, medication adherence issues, and consideration of mineralocorticoid receptor antagonists as fourth-line agents 1, 10
• Elderly patients (≥80 years) should continue treatment 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, 10
• Not addressing lifestyle modifications alongside pharmacological treatment 1, 7
• 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, 10

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
• Monitoring for adverse effects of medications and adjusting therapy as needed is crucial 1