What are the American Heart Association (AHA) guidelines for managing Hypertension (HTN)?

American Heart Association Guidelines for Managing Hypertension

The American Heart Association (AHA) guidelines define hypertension as blood pressure ≥130/80 mmHg and recommend lifestyle modifications as the cornerstone of treatment, with pharmacological therapy added based on blood pressure levels and cardiovascular risk assessment. 1

Blood Pressure Classification

• Normal: <120/80 mmHg 1
• Elevated: 120-129/<80 mmHg 1
• Stage 1 Hypertension: 130-139/80-89 mmHg 1
• Stage 2 Hypertension: ≥140/90 mmHg 1

Accurate Blood Pressure Measurement

• Use validated devices with appropriate cuff size 2
• Take at least 2 readings at each of 2-3 office visits 2
• Consider home BP monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) to confirm diagnosis and rule out white coat hypertension 2, 3
• Record heart rate during BP measurements as a cardiovascular risk factor if >80 beats/min 1

Initial Evaluation

• Identify target organ damage and cardiovascular risk factors 2
• Screen for secondary causes of hypertension, particularly in patients with resistant hypertension, sudden onset, age <30 years, or signs suggesting underlying conditions 2
• Assess cardiovascular risk using appropriate risk calculators 1

Lifestyle Modifications

• DASH diet: rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced saturated and total fat 1, 2, 4
• Sodium restriction: <1500 mg/day or at minimum a reduction of 1000 mg/day 2, 5
• Increased potassium intake: 3500-5000 mg/day 2
• Weight reduction: target ideal body weight or at least 1 kg weight loss if overweight/obese 2, 6
• Physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise, or 3 sessions/week of isometric resistance exercise 2, 6
• Alcohol moderation: ≤2 drinks per day for men and ≤1 per day for women 2, 5
• Smoking cessation 1

Pharmacological Management

• Threshold for initiating drug therapy:

  • Stage 1 hypertension (130-139/80-89 mmHg): Start drug therapy immediately in high-risk patients; try lifestyle modifications for 3-6 months in low-risk patients 2, 1
  • Stage 2 hypertension (≥140/90 mmHg): Start drug therapy immediately along with lifestyle modifications 2, 1

• First-line medications:

  • Thiazide or thiazide-like diuretics 1, 2
  • ACE inhibitors 1, 2
  • Angiotensin Receptor Blockers (ARBs) 1, 2
  • Calcium Channel Blockers (CCBs) 1, 2

• Treatment strategy:

  • Start with monotherapy at low dose and titrate to effective doses before adding new agents 2
  • Consider combination therapy for stage 2 hypertension 1
  • Use once-daily dosing when possible to improve adherence 1

Blood Pressure Targets

• General population: <130/80 mmHg 1
• Adults >80 years: Consider treatment when SBP ≥160 mmHg 1
• Individualize targets based on comorbidities, tolerability, and patient preferences 1, 2

Special Populations

• Coronary artery disease: Beta-blockers and ACE inhibitors/ARBs recommended 1, 2
• Heart failure: ACE inhibitors/ARBs, beta-blockers, and diuretics recommended 1, 2
• Chronic kidney disease: ACE inhibitors or ARBs recommended, especially with albuminuria 2
• Diabetes: ACE inhibitors or ARBs recommended 2
• Elderly patients: 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 medication side effects and adherence at each visit 2
• Implement team-based care approaches to improve hypertension control 1

Strategies to Improve Adherence

• Simplify medication regimens with once-daily dosing 1
• Use fixed-dose combinations when possible 1
• Implement effective behavioral and motivational strategies 1
• Consider financial incentives and reduced copayments to improve adherence 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 BP monitoring 2, 3
• Not addressing medication non-adherence 1, 2
• Overlooking potential drug interactions 2
• Abandoning lifestyle modifications after starting medications 2, 7
• Using beta-blockers as first-line therapy unless specific indications exist 2
• Not considering secondary causes in resistant hypertension 2