What are the guidelines for managing hypertension?

Hypertension Management Guidelines

The optimal management of hypertension requires a combination of lifestyle modifications and pharmacological therapy targeting a blood pressure of ≤140/85 mmHg for most adults, with lower targets of ≤130/80 mmHg for patients with diabetes, renal impairment, or established cardiovascular disease. 1, 2

Diagnosis and Assessment

• 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 to determine accurate blood pressure thresholds 1
• Ambulatory blood pressure monitoring is indicated for unusual BP variability, suspected white coat hypertension, resistant hypertension (requiring three or more drugs), or when symptoms suggest hypotension 1, 3
• Routine investigations for hypertensive patients should include:
  • Urine strip test for blood and protein
  • Blood electrolytes and creatinine
  • Blood glucose
  • Serum total:HDL cholesterol ratio
  • 12-lead ECG 3, 1
• Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions 1

Treatment Thresholds

• Urgent treatment is needed for blood pressure ≥180/110 mmHg or for malignant hypertension with impending complications 3, 2
• All patients with confirmed BP ≥140/90 mmHg should receive prompt lifestyle measures and pharmacological treatment 2
• For BP 140-159/90-99 mmHg, treatment decisions should consider the presence of target organ damage, established cardiovascular disease, diabetes, and 10-year cardiovascular disease risk ≥20% 1, 2
• Systolic blood pressure is at least as important as diastolic blood pressure as a predictor of cardiovascular disease 3

Treatment Targets

• The hypertension optimal treatment (HOT) trial reported that optimal blood pressure for reduction of major cardiovascular events was 139/83 mmHg 3
• 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 blood pressure is ≤130/80 mmHg 1, 2
• When using ambulatory BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents 2

Lifestyle Modifications

• Lifestyle modifications should be recommended to all patients with hypertension and those with borderline or high-normal blood pressure 1, 2
• Evidence-based lifestyle interventions include:
  • Weight reduction to achieve an ideal body weight via reduced fat and total calorie intake 3, 4
  • Regular physical activity (predominantly dynamic exercise like brisk walking) 3, 4
  • Limiting alcohol consumption to <21 units/week for men and <14 units/week for women 3, 4
  • Reduced sodium intake and elimination of excessively salty foods 3, 4
  • Increased consumption of fruits and vegetables 3, 4
  • Smoking cessation 3, 5

Pharmacological Management

• First-line drug therapy for hypertension includes:
  • Thiazide or thiazide-like diuretics
  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)
  • Calcium channel blockers (CCBs) 1, 2, 6
• For most patients with confirmed hypertension, combination therapy is often needed as many patients require more than one drug to achieve blood pressure goals 2, 7, 8
• Preferred combinations include a renin-angiotensin system (RAS) blocker (like lisinopril) with either a dihydropyridine CCB (like amlodipine) or diuretic 2
• Lowering blood pressure reduces the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions 7, 8

Special Considerations

• 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
• Resistant hypertension (uncontrolled BP despite use of 3 or more antihypertensive agents) requires evaluation for pseudoresistance, secondary causes, and intake of interfering substances 9
• Mineralocorticoid receptor antagonists are effective add-on agents for resistant hypertension 9
• Indications for specialist referral include:
  • Urgent treatment needed for malignant hypertension or impending complications
  • Investigation of potential underlying causes
  • Therapeutic problems or failures
  • Special circumstances like unusually variable BP, suspected white coat hypertension, or pregnancy 3

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
• Not addressing lifestyle modifications alongside pharmacological treatment 1, 5
• Overlooking the need for lower BP targets in high-risk patients (diabetes, chronic kidney disease, established cardiovascular disease) 1, 2
• Not considering secondary causes in resistant hypertension or young patients 1, 9

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
• Monitoring for adverse effects of medications and adjusting therapy as needed is crucial 1