What are the guidelines for managing hypertension?

Hypertension Management Guidelines

The most current guidelines recommend initiating drug treatment for all patients with sustained systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥100 mmHg despite lifestyle modifications, with a target blood pressure of ≤140/85 mmHg for most patients and ≤130/80 mmHg for those with diabetes, renal impairment, or established cardiovascular disease. 1, 2, 3

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
• 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 4, 1
• When using ABPM or home readings, values are expected to be approximately 10/5 mmHg lower than office readings for both thresholds and targets 1, 2

Initial Assessment

• Routine investigations for hypertensive patients should include:
  • Urine strip test for blood and protein 4, 1
  • Blood electrolytes and creatinine 4, 1
  • Blood glucose 4, 1
  • Serum total:HDL cholesterol ratio 4, 1
  • 12-lead electrocardiograph 4, 1
• Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions 1, 2

Treatment Thresholds

• Drug treatment should be started in all patients with:
  • Sustained systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥100 mmHg despite lifestyle modifications 1, 2
  • Systolic blood pressure 140-159 mmHg or diastolic blood pressure 90-99 mmHg 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% 4, 1
• Urgent treatment is needed for:
  • Accelerated hypertension (severe hypertension with grade III-IV retinopathy) 4, 1
  • Particularly severe hypertension (>220/120 mmHg) 4, 1
  • Impending complications (e.g., transient ischemic attack, left ventricular failure) 4, 1

Treatment Targets

• For most patients, the target blood pressure is ≤140 mmHg systolic and ≤85 mmHg diastolic 1, 2, 3
• For patients with diabetes, renal impairment, or established cardiovascular disease, the target blood pressure is ≤130/80 mmHg 1, 2, 3
• Optimal blood pressure for reduction of major cardiovascular events has been reported to be 139/83 mmHg 4
• Lowering blood pressure reduces the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions 5, 6, 7

Lifestyle Modifications

• Lifestyle modifications should be recommended to all patients with hypertension and those with borderline or high-normal blood pressure 4, 1, 2
• Effective lifestyle interventions include:
  • Weight reduction to achieve ideal body weight via reduced fat and total calorie intake 4, 7
  • Regular physical activity (predominantly dynamic exercise like brisk walking) 4, 7
  • Limiting alcohol consumption (<21 units/week for men, <14 units/week for women) 4, 8
  • Reduced sodium intake and elimination of excessively salty foods 4, 8, 9
  • Increased consumption of fruits, vegetables, and low-fat dairy products (DASH diet) 10, 8, 9
  • Smoking cessation 4, 7

Pharmacological Management

• First-line drug therapy includes:
  • Thiazide or thiazide-like diuretics 1, 2, 7
  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) 1, 2, 5, 6
  • Calcium channel blockers 1, 2, 5
  • Beta-blockers 1
• For most patients with confirmed hypertension, combination therapy is often recommended as initial treatment 2, 3, 7
• Preferred combinations include a renin-angiotensin system blocker with either a calcium channel blocker or diuretic 2, 3
• Antihypertensive medications should be titrated according to office and home BP levels to achieve target blood pressure 7

Special Considerations

• Secondary hypertension should be suspected in cases of:
  • Elevated serum creatinine or proteinuria/hematuria 4, 1
  • Sudden onset or worsening of hypertension 4, 1
  • Resistance to multiple drugs (≥3 drugs) 4, 1, 11
  • Young age (any hypertension <20 years; needing treatment <30 years) 4, 1
  • Electrolyte abnormalities suggesting endocrine causes 1, 11
• Resistant hypertension requires evaluation for:
  • Medication adherence issues 1, 11
  • Secondary causes 1, 11
  • Consideration of mineralocorticoid receptor antagonists as fourth-line agents 11

Monitoring and Follow-up

• After treatment initiation, patients should be seen frequently until BP is controlled 2, 3
• Regular monitoring of BP (office and home readings when possible) is necessary 1, 2, 3
• Annual reassessment of cardiovascular risk is recommended 1, 2
• Monitoring for adverse effects of medications and adjusting therapy as needed is crucial 1