What are the guidelines for managing hypertension (HTN)?

Guidelines for Hypertension Management

The current guidelines recommend treating hypertension with both lifestyle modifications and pharmacological therapy, with a target blood pressure of <140/85 mmHg for most adults and <130/80 mmHg for patients with diabetes, renal impairment, or established cardiovascular disease. 1, 2, 3

Diagnosis and Classification

• 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, or resistant hypertension 1
• Routine investigations should include urine testing for blood and protein, blood electrolytes and creatinine, blood glucose, serum cholesterol, and 12-lead ECG 1

Treatment Thresholds

• Initiate antihypertensive drug therapy if sustained systolic blood pressure ≥160 mmHg or sustained diastolic blood pressure ≥100 mmHg 4, 1
• For patients with sustained systolic blood pressure 140-159 mmHg or sustained diastolic blood pressure 90-99 mmHg, consider initiating treatment if cardiovascular disease, target organ damage, diabetes, or estimated 10-year cardiovascular disease risk ≥20% 4, 1
• For patients with diabetes, initiate antihypertensive drug treatment if systolic blood pressure is sustained ≥140 mmHg or diastolic blood pressure is sustained ≥90 mmHg 4

Treatment Targets

• For most non-diabetic patients: optimal target is <140/85 mmHg with a minimum acceptable level (audit standard) of <150/90 mmHg 4, 1, 2
• For patients with diabetes, chronic renal disease, or established cardiovascular disease: optimal target is <130/80 mmHg 4, 1, 2

Lifestyle Modifications

• All patients with hypertension or elevated blood pressure should receive lifestyle modification advice 1, 5
• Effective lifestyle interventions include:
  • Weight reduction to achieve ideal body weight 4, 1
  • Regular physical exercise (predominantly dynamic, like brisk walking) 4, 6
  • Limiting alcohol consumption (<21 units/week for men, <14 units/week for women) 4, 1
  • Reduced sodium intake and elimination of excessively salty foods 4, 6
  • Increased consumption of fruits and vegetables 4, 5
  • Smoking cessation 4, 6

Pharmacological Management

• Most patients with hypertension will require at least two blood pressure lowering drugs to achieve recommended goals 4, 6
• First-line drug therapy includes:
  • Thiazide or thiazide-like diuretics 1, 6
  • Angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril) 7, 6
  • Angiotensin receptor blockers (ARBs) 1, 6
  • Calcium channel blockers (e.g., amlodipine) 8, 6
• Preferred combinations include a renin-angiotensin system (RAS) blocker with either a calcium channel blocker or diuretic 2, 3
• Fixed-dose combinations are recommended when no cost disadvantages exist to improve adherence 4, 3

Special Considerations

Resistant Hypertension

• Defined as BP remaining uncontrolled despite use of 3 or more antihypertensive agents 9
• Consider secondary causes, medication adherence, and lifestyle factors 1, 9
• Mineralocorticoid receptor antagonists are effective add-on agents, usually as a fourth drug 9

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
• Requires specialist referral for further investigation 4

Additional Cardiovascular Risk Reduction

• Aspirin (75 mg daily) is recommended for:
  • Secondary prevention in all patients unless contraindicated 4
  • Primary prevention in patients aged ≥50 years with controlled BP (<150/90 mmHg) and 10-year CVD risk ≥20% 4
• Statins are recommended for:
  • All patients with hypertension complicated by cardiovascular disease 4
  • Primary prevention in patients with 10-year CVD risk ≥20% and total cholesterol ≥3.5 mmol/l 4

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
• Allow four weeks to observe the full response to medication unless urgent BP lowering is required 4