What are the recommended blood pressure parameters and management strategies for hypertension?

Recommended Blood Pressure Parameters and Management Strategies for Hypertension

The target blood pressure for most adults should be 120-129/<80 mmHg to optimally reduce cardiovascular disease risk, with first-line pharmacotherapy consisting of ACE inhibitors/ARBs, calcium channel blockers, and thiazide/thiazide-like diuretics. 1

Blood Pressure Classification and Thresholds

• Hypertension is defined as persistent systolic blood pressure (SBP) ≥130 mmHg or diastolic blood pressure (DBP) ≥80 mmHg 2
• Blood pressure categories according to the most recent guidelines:
  • Normal: <120/80 mmHg 3
  • Elevated: 120-129/<80 mmHg 1
  • Stage 1 hypertension: 130-139/80-89 mmHg 1
  • Stage 2 hypertension: ≥140/90 mmHg 1

Blood Pressure Targets

General Population

• The first objective of treatment should be to lower BP to <140/90 mmHg in all patients 1
• For optimal cardiovascular risk reduction, systolic BP should be targeted to 120-129 mmHg in most adults, provided treatment is well tolerated 1
• Diastolic BP target should be <80 mmHg for all hypertensive patients 1
• If systolic BP is at target (120-129 mmHg) but diastolic BP remains ≥80 mmHg, consider intensifying treatment to achieve diastolic BP of 70-79 mmHg 1

Special Populations

• Older adults (≥65 years): Target systolic BP of 130-139 mmHg 1
• Adults ≥85 years: Consider more lenient targets (<140 mmHg) 1
• Patients with frailty or limited life expectancy (<3 years): Consider more lenient targets (<140/90 mmHg) 1
• Patients with diabetes or chronic kidney disease: Target <130/80 mmHg 1

Pharmacological Management

First-Line Medications

• Four major classes are recommended as first-line agents 1:
  • ACE inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Calcium channel blockers (preferably dihydropyridine)
  • Thiazide or thiazide-like diuretics (especially chlorthalidone and indapamide)

Treatment Strategy

• For most patients with confirmed hypertension (≥140/90 mmHg), combination therapy is recommended as initial treatment 1
• Preferred initial combinations include a RAS blocker (ACE inhibitor or ARB) with either a calcium channel blocker or diuretic 1
• Fixed-dose single-pill combinations are recommended to improve adherence 1
• If BP is not controlled with a two-drug combination, increase to a three-drug combination (typically RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic) 1
• For resistant hypertension (uncontrolled on 3 drugs), add spironolactone or, if not tolerated, eplerenone, beta-blocker, or other agents 1
• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1

Special Considerations

• In Black patients, including those with diabetes, thiazide diuretics and calcium channel blockers are recommended as first-line agents 1
• Beta-blockers should be combined with other agents when there are specific indications (e.g., heart failure with reduced ejection fraction, post-myocardial infarction) 1
• For stage 2 hypertension (≥160/100 mmHg), initiate with two antihypertensive agents from different classes 1

Non-Pharmacological Management

• Regular physical activity: 150 min of moderate-intensity or 75 min of vigorous-intensity aerobic exercise per week, plus resistance training 2-3 times/week 1
• Weight management: Target healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Dietary modifications:
  • Mediterranean or DASH diet with increased consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids 1
  • Reduced sodium intake 2, 4
  • Increased potassium intake 2, 4
• Alcohol restriction:
  • <14 units/week for men
  • <8 units/week for women
  • Preferably avoid alcohol completely for best health outcomes 1
• Smoking cessation 1

Monitoring and Follow-up

• After initiation of drug therapy, monthly evaluation of adherence and therapeutic response until control is achieved 1
• Home blood pressure monitoring (HBPM) and team-based care are useful in improving BP control 1
• Maintain BP-lowering drug treatment lifelong, even beyond age 85 if well tolerated 1

Common Pitfalls and Caveats

• Failure to recognize white coat hypertension or masked hypertension can lead to inappropriate treatment decisions 1
• Orthostatic hypotension should be monitored but is not associated with higher rates of cardiovascular events and should not be a reason to withdraw or down-titrate treatment if asymptomatic 1
• Resistant hypertension (BP ≥130/80 mmHg on ≥3 medications or controlled BP requiring ≥4 medications) requires exclusion of pseudo-resistance (inaccurate measurement, white coat effect, or poor adherence) 1
• Device-based therapies such as renal denervation are not recommended for routine treatment of hypertension outside clinical studies 1