What is the guideline for treatment of hypertension?

Guidelines for Treatment of Hypertension

The 2020 International Society of Hypertension (ISH) guidelines recommend a structured approach to hypertension management that includes lifestyle modifications for all patients and drug therapy based on blood pressure levels, with target blood pressure of <130/80 mmHg for most patients. 1

Diagnosis and Classification

• Hypertension is diagnosed when office blood pressure readings are consistently ≥140/90 mmHg, with confirmation using home or ambulatory blood pressure monitoring 1
• Use validated automated upper arm cuff devices with appropriate cuff size, measuring both arms at first visit and subsequently using the arm with higher readings 1
• Home BP readings should be <135/85 mmHg and 24-hour ambulatory BP <130/80 mmHg to be considered normal 1

Treatment Approach

Lifestyle Modifications (First-line for all patients)

• Weight reduction to achieve ideal body weight through reduced calorie intake 1, 2
• Regular physical activity (predominantly dynamic exercise like brisk walking) 2, 3
• Dietary modifications: DASH diet (rich in fruits, vegetables, low-fat dairy) 2, 3
• Sodium restriction to <2g/day 2, 4
• Alcohol moderation (≤2 standard drinks/day for men, ≤1 for women) 1, 2
• Smoking cessation 2, 5
• Stress management when appropriate 6, 4

Pharmacological Treatment

When to Start Medications:

• Immediately in high-risk patients (with cardiovascular disease, chronic kidney disease, diabetes, organ damage, or aged 50-80 years) with BP ≥140/90 mmHg 1
• After 3-6 months of lifestyle intervention in low-moderate risk patients with persistent BP ≥140/90 mmHg 1

Drug Selection Algorithm:

For Non-Black Patients:

1. Start with low dose ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB) 1, 7
2. Increase to full dose if needed 1
3. Add thiazide/thiazide-like diuretic 1
4. Add calcium channel blocker (CCB) 1, 8
5. Add spironolactone or, if not tolerated, consider amiloride, doxazosin, eplerenone, clonidine or beta-blocker 1

For Black Patients:

1. Start with low dose ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic 1
2. Increase to full dose 1
3. Add diuretic or ACEI/ARB (whichever wasn't used initially) 1
4. Add spironolactone or, if not tolerated, consider amiloride, doxazosin, eplerenone, clonidine or beta-blocker 1

Special Populations

Patients with Comorbidities

• Coronary Artery Disease: Target BP <130/80 mmHg (<140/80 in elderly). Use RAS blockers, beta-blockers with or without CCBs 1
• Previous Stroke: Target BP <130/80 mmHg (<140/80 in elderly). Use RAS blockers, CCBs, and diuretics 1
• Heart Failure: Target BP <130/80 mmHg but >120/70 mmHg. Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1
• Chronic Kidney Disease: Target BP depends on proteinuria level. Use RAS blockers as first-line 1
• Diabetes: Target BP <130/80 mmHg. Prefer RAS inhibitors and CCBs 1
• Metabolic Syndrome: Focus on lifestyle modifications plus BP control according to standard targets 1

Resistant Hypertension

• Defined as BP >140/90 mmHg despite treatment with three or more medications including a diuretic 1
• Rule out pseudoresistance (poor measurement technique, white coat effect, nonadherence) 1
• Consider spironolactone as fourth-line agent 1

Monitoring and Follow-up

• Aim to achieve target BP within 3 months 1
• Target BP <130/80 mmHg for most patients, individualized for elderly based on frailty 1, 9
• Monitor for medication adherence using objective methods when possible 1
• If BP remains uncontrolled, refer to a hypertension specialist 1

Common Pitfalls to Avoid

• Failing to confirm office readings with home or ambulatory monitoring 1
• Not addressing lifestyle modifications alongside pharmacological treatment 2, 3
• Inadequate dosing or inappropriate drug combinations 1
• Not considering secondary causes in resistant hypertension 1
• Poor medication adherence assessment 1
• Neglecting comorbidities when selecting antihypertensive agents 1