What are the guidelines for managing hypertension?

Hypertension Management Guidelines

The management of hypertension requires a combination of lifestyle modifications and pharmacological therapy, with treatment targets of ≤140/85 mmHg for most adults and ≤130/80 mmHg for high-risk patients with diabetes, renal impairment, or established cardiovascular disease. 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 (ABPM) is indicated when clinic blood pressure shows unusual variability, when hypertension is resistant to drug treatment, when symptoms suggest hypotension, or to diagnose white coat hypertension 3
• 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

Treatment Thresholds

• Urgent treatment is needed for accelerated hypertension, severe hypertension (≥180/110 mmHg), or impending complications 1, 2
• Standard treatment thresholds include starting drug treatment 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 should be initiated if target organ damage, established cardiovascular disease, diabetes, or 10-year CVD risk ≥ 20% is present 1, 2

Treatment Targets

• For most patients, the target blood pressure is ≤ 140 mmHg systolic and ≤ 85 mmHg diastolic 1, 2
• For high-risk patients with diabetes, renal impairment, or established cardiovascular disease, the target blood pressure is ≤ 130/80 mmHg 1, 2
• The Hypertension Optimal Treatment (HOT) trial found that optimal blood pressure for reduction of major cardiovascular events was 139/83 mmHg 3
• When using ambulatory BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents 2

Lifestyle Modifications

• Lifestyle modifications should be recommended to all patients with hypertension and those with borderline or high-normal blood pressure 1, 2
• Evidence-based lifestyle interventions include:
  • Weight reduction to achieve ideal body weight via reduced fat and total calorie intake 3, 4
  • Regular physical activity designed to improve fitness (predominantly dynamic exercise like brisk walking) 3, 5
  • Limiting alcohol consumption to < 21 units per week for men and < 14 units per week for women 3
  • Reduced use of salt when preparing food and elimination of excessively salty foods 3, 4
  • Increased consumption of fruits and vegetables 3, 6
  • Adoption of the DASH diet (high in fruits, vegetables, and low-fat dairy products) which can lower BP as effectively as some antihypertensive drugs 4, 6

Pharmacological Management

• First-line drug therapy includes thiazide or thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and calcium channel blockers 1, 2, 7
• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is often recommended as initial treatment 2, 7
• Amlodipine is indicated for the treatment of hypertension and can be used alone or in combination with other antihypertensive agents 8
• Spironolactone is indicated as add-on therapy for the treatment of hypertension in patients not adequately controlled on other agents 9
• An SBP reduction of 10 mmHg decreases risk of cardiovascular disease events by approximately 20% to 30% 7

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
• Indications for specialist referral include:
  • Urgent treatment indicated for malignant hypertension or impending complications
  • Investigation of potential underlying causes of hypertension
  • Evaluation of therapeutic problems or failures
  • Special circumstances such as unusually variable blood pressure, possible white coat hypertension, or pregnancy 3

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, 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

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