What are the guidelines for managing hypertension?

Guidelines for Managing Hypertension

The European Society of Cardiology recommends that for most adults with hypertension, the target blood pressure is ≤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

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 1, 2
• Hypertension is classified as: Normal: <120/80 mmHg, Elevated/Prehypertension: 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, resistant hypertension, or when symptoms suggest hypotension 1, 3
• Home BP readings are typically 10/5 mmHg lower than office readings and should be considered when evaluating BP control 2

Initial Assessment

• Routine investigations should include urine testing for blood and protein, blood electrolytes and creatinine, blood glucose, serum total:HDL cholesterol ratio, and 12-lead ECG 1, 3
• Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions 1, 3

Treatment Thresholds

• Initiate antihypertensive drug treatment in people with sustained systolic blood pressure >160 mm Hg or sustained diastolic blood pressure >100 mm Hg 3, 1
• For BP 140-159/90-99 mmHg, treatment decisions should consider target organ damage, established cardiovascular disease, diabetes, or 10-year cardiovascular disease risk ≥20% 3, 2
• Urgent treatment is needed for accelerated hypertension, severe hypertension, or impending complications 1, 2

Treatment Targets

• Optimal blood pressure treatment targets are systolic blood pressure <140 mmHg and diastolic blood pressure <85 mmHg 3, 1
• For patients with diabetes, renal impairment, or established cardiovascular disease, the target blood pressure is ≤130/80 mmHg 1, 2
• The minimum acceptable level of control (audit standard) is <150/<90 mmHg 3

Lifestyle Modifications

• Non-pharmacological advice should be offered to all hypertensive people and those with a strong family history of hypertension 3, 1
• Effective lifestyle interventions include:
  • Weight reduction to achieve ideal body weight 3, 4
  • Regular physical activity (predominantly dynamic exercise like brisk walking) 3, 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, 6
  • Increased consumption of fruits, vegetables, and low-fat dairy products (DASH diet) 6, 1
  • Smoking cessation 3, 5

Pharmacological Management

• First-line agents include thiazide or thiazide-like diuretics, ACE inhibitors or ARBs, calcium channel blockers, and beta-blockers 3, 1
• In the absence of contraindications or compelling indications, low-dose thiazide diuretics or β-blockers are preferred as first-line treatment 3, 4
• For most patients with confirmed hypertension, combination therapy is often recommended as initial treatment 2, 4
• Preferred combinations include a renin-angiotensin system (RAS) blocker with either a calcium channel blocker or diuretic 2, 4
• Spironolactone is indicated as add-on therapy for hypertension when patients are not adequately controlled on other agents 7
• Amlodipine may be used alone or in combination with other antihypertensive agents for the treatment of hypertension 8

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, 9
• Indications for specialist referral include:
  • Urgent treatment for malignant hypertension or impending complications 3
  • Investigation of potential underlying causes 3
  • Therapeutic problems or failures 3
  • Special circumstances such as unusually variable BP, possible white coat hypertension, or pregnancy 3

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
• After treatment initiation, patients should be seen frequently (every 1-3 months) until BP is controlled 9
• Monitoring for adverse effects of medications and adjusting therapy as needed is crucial 1

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