Guidelines for Managing Hypertension
The management of hypertension requires a combination of lifestyle modifications and pharmacological therapy, with target blood pressure ≤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
- Hypertension is classified as: Normal: <120/80 mmHg, Elevated: 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, 4
- Home BP readings are typically 10/5 mmHg lower than office readings and should be considered in assessment 2, 3
Initial Evaluation
- Routine investigations should include:
- Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions 1
Treatment Thresholds
- Urgent treatment is needed for BP ≥180/110 mmHg or accelerated hypertension 1, 2
- For confirmed hypertension (≥140/90 mmHg), immediate initiation of both lifestyle interventions and pharmacological therapy is recommended 2, 3
- For BP 140-159/90-99 mmHg, treatment decisions should consider target organ damage, established cardiovascular disease, diabetes, and cardiovascular risk 1, 2
Lifestyle Modifications
- All hypertensive patients should receive lifestyle modification recommendations 1, 2, 3
- Effective interventions include:
- Weight reduction to achieve ideal body weight 4, 5
- Regular physical activity (30-60 minutes, 4-7 days per week) 1, 6
- Limiting alcohol consumption (<21 units/week for men, <14 units/week for women) 4, 7
- Reduced sodium intake and increased potassium intake 1, 6
- Diet rich in fruits, vegetables, low-fat dairy products, and reduced in saturated fat 5, 6
- Smoking cessation 5, 8
Pharmacological Management
- First-line agents include:
- For most patients with confirmed hypertension, combination therapy is often needed to achieve targets 2, 5
- Preferred combinations include a renin-angiotensin system blocker (ACE inhibitor or ARB) with either a CCB or diuretic 2, 5
- Fixed-dose single-pill combinations improve adherence 3
Treatment Targets
- For most patients, the target blood pressure is ≤140/85 mmHg 1, 2
- For patients with diabetes, renal impairment, or established cardiovascular disease, the target is ≤130/80 mmHg 1, 2, 3
- Optimal blood pressure for reduction of major cardiovascular events is approximately 139/83 mmHg 4
Special Populations
Resistant Hypertension
- Consider secondary causes, medication adherence, and interfering substances 1, 9
- Add a mineralocorticoid receptor antagonist as a fourth agent when appropriate 9
Secondary Hypertension
- Suspect with elevated serum creatinine, proteinuria, sudden onset or worsening of hypertension, resistance to multiple drugs, young age, or electrolyte abnormalities 1, 9
Elderly Patients
Monitoring and Follow-up
- After treatment initiation, patients should be seen frequently (every 1-3 months) until BP is controlled 3
- Regular monitoring of BP (office and home readings when possible) is necessary 1, 2
- Annual reassessment of cardiovascular risk is recommended 1, 2
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
- Overlooking the need for lower BP targets in high-risk patients 1, 3
- Not considering secondary causes in resistant hypertension or young patients 1, 9