What are the current guidelines for managing hypertension and achieving target blood pressure?

Current Hypertension Management Guidelines

The current guidelines recommend a target blood pressure of <130/80 mmHg for most adults with hypertension to reduce cardiovascular and renal morbidity and mortality. 1, 2

Blood Pressure Classification and Targets

• Hypertension is defined as persistent systolic blood pressure (SBP) ≥130 mmHg or diastolic blood pressure (DBP) ≥80 mmHg 2
• Initial target for all adults should be <140/90 mmHg, then aim for 120-129/<80 mmHg if well tolerated 1
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, target blood pressure should be <130/80 mmHg 1
• For older patients (≥65 years), target systolic blood pressure of 130-139 mmHg is recommended to balance benefits and risks 1

Treatment Initiation Thresholds

• Immediate antihypertensive drug therapy is recommended if:
  • Sustained SBP ≥160 mmHg or DBP ≥100 mmHg (Stage 2 hypertension) 1
  • SBP 140-159/90-99 mmHg (Stage 1 hypertension) in high-risk patients (with cardiovascular disease, chronic kidney disease, or diabetes) 3, 1
• For SBP 130-139/80-89 mmHg (previously called prehypertension, now Stage 1 hypertension in some guidelines), consider drug therapy if 10-year cardiovascular risk is ≥10% 3

First-Line Pharmacological Treatment

• First-line medications include:
  • Thiazide or thiazide-like diuretics 3, 2
  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) 3, 4, 5
  • Calcium channel blockers (CCBs) 5, 2
• For non-Black patients, start with an ACE inhibitor/ARB, CCB, or thiazide-like diuretic 3
• For Black patients, start with a CCB or thiazide-like diuretic, or combination therapy 3

Combination Therapy

• Most patients with hypertension will require at least two blood pressure-lowering drugs to achieve recommended goals 1, 2
• If blood pressure is >20/10 mmHg above target, consider initiating therapy with two agents 3
• When using combination therapy, pair medications from different classes:
  • ACE inhibitor/ARB + CCB or thiazide-like diuretic 3
  • Avoid combining ACE inhibitors with ARBs due to increased adverse effects without additional benefit 3

Monitoring and Follow-Up

• After medication adjustments, blood pressure should be rechecked within 4 weeks 1, 6
• Target blood pressure control should be achieved within 3 months 3, 1
• Use home blood pressure monitoring to confirm control, with target readings of <135/85 mmHg for home measurements 1, 6

Treatment of Resistant Hypertension

• If blood pressure remains uncontrolled on a three-drug regimen (typically ACE inhibitor/ARB + CCB + diuretic), add spironolactone as fourth-line therapy 1
• If spironolactone is not tolerated or contraindicated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 3

Special Considerations

• For elderly patients, medication changes should be made gradually to minimize adverse effects 6
• The International Society of Hypertension guidelines recommend reducing BP by at least 20/10 mmHg, ideally to target levels 3
• The evidence for targeting SBP <120 mmHg is mixed, with some studies showing benefit but others showing no difference in total mortality or cardiovascular mortality 7, 8

Lifestyle Modifications

• All patients should be advised on lifestyle modifications including:
  • Regular aerobic exercise (30-60 minutes, 4-7 days per week) 9, 10
  • Weight management (target BMI 18.5-24.9 kg/m²) 9, 10
  • Dietary sodium restriction (<100 mmol/day) 10
  • Limited alcohol consumption (≤14 drinks/week for men, ≤9 drinks/week for women) 9
  • Diet rich in fruits, vegetables, and low-fat dairy products 9, 10

The most recent guidelines have shifted toward more aggressive blood pressure targets compared to older recommendations, reflecting evolving evidence that lower targets may provide greater cardiovascular protection. However, treatment should always consider individual patient factors including age, comorbidities, and medication tolerance.