American Heart Association (AHA) Guidelines for Managing Hypertension
The American Heart Association (AHA) defines hypertension as blood pressure ≥130/80 mmHg and recommends a combination of lifestyle modifications and pharmacological therapy based on blood pressure category and cardiovascular risk assessment. 1
Blood Pressure Classification
- Normal BP: <120/80 mmHg 1, 2
- Elevated BP: 120-129/<80 mmHg (formerly "prehypertension") 1
- Stage 1 Hypertension: 130-139/80-89 mmHg 1
- Stage 2 Hypertension: ≥140/90 mmHg 1
Diagnosis and Assessment
- Diagnosis requires proper measurement technique with validated devices and appropriate cuff size 2
- BP should be measured at least twice during each visit and averaged over 2-3 office visits 2
- Out-of-office BP measurements (home or ambulatory monitoring) are recommended to confirm diagnosis and rule out white coat hypertension 2, 3
- Initial evaluation should assess for target organ damage, cardiovascular risk factors, and potential secondary causes of hypertension 2
Cardiovascular Risk Assessment
- The ACC/AHA recommends using the ASCVD Risk Calculator to estimate 10-year risk of cardiovascular disease 1
- Risk assessment helps determine the threshold for initiating pharmacological therapy 1
Non-Pharmacological Management
- Dietary Modifications: DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy products) 1, 2, 4
- Sodium Restriction: <1500 mg/day or reduction of at least 1000 mg/day 2, 5
- Increased Potassium Intake: 3500-5000 mg/day (unless contraindicated) 2, 5
- Weight Management: Target BMI <25 kg/m² or at least 1 kg weight loss if overweight/obese 2, 6
- Physical Activity: 90-150 minutes/week of aerobic exercise, dynamic resistance exercise 3 times/week, or isometric resistance exercises 2, 6
- Alcohol Moderation: ≤2 drinks/day for men and ≤1 drink/day for women 2, 5
Pharmacological Management
Thresholds for Initiating Drug Therapy
Stage 1 Hypertension (130-139/80-89 mmHg):
Stage 2 Hypertension (≥140/90 mmHg):
First-Line Medications
- Primary agents: Thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers 1, 2
- Initial therapy:
Blood Pressure Targets
- General target: <130/80 mmHg for most adults 1
- Older adults (≥65 years): Target SBP <130 mmHg if tolerated 1
- Patients with comorbidities: May require specific BP targets and medication choices 1, 2
Special Populations
- Coronary Artery Disease: Beta-blockers and ACE inhibitors/ARBs are preferred 1, 2
- Heart Failure: ACE inhibitors/ARBs, beta-blockers, diuretics, and mineralocorticoid receptor antagonists are recommended 1, 2
- Chronic Kidney Disease: ACE inhibitors or ARBs are preferred, especially with albuminuria 2
- Diabetes: ACE inhibitors or ARBs are preferred 2
- Elderly: Start with lower doses and titrate gradually to avoid orthostatic hypotension 2
Monitoring and Follow-up
- Follow up monthly for dose adjustments until BP is controlled 2
- Once BP is controlled, follow up every 3-6 months 2
- Monitor for medication side effects and adherence at each visit 1, 2
- Consider team-based care approaches to improve BP control 1
Strategies to Improve Adherence
- Simplify medication regimens (once-daily dosing when possible) 1
- Use fixed-dose combination pills when appropriate 1, 2
- Implement effective behavioral and motivational strategies 1
- Address financial barriers through health system financing strategies 1
- Develop a clear, detailed plan of care for each patient 1
Common Pitfalls to Avoid
- Failing to confirm office readings with home or ambulatory monitoring 2, 3
- Not addressing medication non-adherence 1, 2
- Neglecting lifestyle modifications after starting medications 2
- Using beta-blockers as first-line therapy unless specifically indicated 2
- Setting overly aggressive BP targets in frail elderly patients or those with orthostatic hypotension 2, 3