What are the current recommendations for managing hypertension according to the latest guidelines?

Current Recommendations for Hypertension Management According to the Latest Guidelines

According to the 2020 International Society of Hypertension (ISH) global guidelines, hypertension management should follow a structured approach with blood pressure targets of <130/80 mmHg for most adults, with specific medication algorithms based on patient demographics and comorbidities. 1

Diagnosis of Hypertension

• Hypertension is diagnosed when office blood pressure measurements are consistently ≥140/90 mmHg 1
• For initial evaluation, use the average of multiple readings with a validated automated upper arm cuff device with appropriate cuff size 1
• If office BP is ≥130/85 mmHg, confirm with home BP monitoring (target <135/85 mmHg) or 24-hour ambulatory BP monitoring (target <130/80 mmHg) 1
• At first visit, measure BP in both arms simultaneously; if there is a consistent difference, use the arm with the higher BP for subsequent measurements 1

Treatment Thresholds and Initial Management

• Grade 1 Hypertension (140-159/90-99 mmHg):

  • Start lifestyle interventions immediately for all patients 1
  • Initiate drug treatment immediately in high-risk patients (those with CVD, CKD, diabetes, organ damage, or aged 50-80 years) 1
  • For low-moderate risk patients, try lifestyle modifications for 3-6 months before starting medications if BP remains elevated 1

• Grade 2 Hypertension (≥160/100 mmHg):

  • Start both lifestyle interventions and drug treatment immediately for all patients 1

Lifestyle Modifications

• Implement aerobic exercise for 30-60 minutes, 4-7 days per week 2, 3
• Maintain healthy body weight (BMI 18.5-24.9 kg/m²) and waist circumference (<102 cm for men, <88 cm for women) 3
• Follow a DASH diet (rich in fruits, vegetables, low-fat dairy products, reduced in saturated fat and cholesterol) 2, 4
• Restrict sodium intake and increase potassium intake 5
• Limit alcohol consumption (≤14 standard drinks/week for men, ≤9 for women) 3, 6
• Smoking cessation for all patients 6
• Consider stress management in selected individuals 5

Pharmacological Treatment Algorithm

For Non-Black Patients:

1. Start with low-dose ACE inhibitor or ARB 1
2. Increase to full dose 1
3. Add thiazide/thiazide-like diuretic 1
4. If BP still uncontrolled, add spironolactone (or if not tolerated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker) 1

For Black Patients:

1. Start with low-dose ARB plus either:
   • DHP-CCB (dihydropyridine calcium channel blocker) or
   • DHP-CCB plus thiazide/thiazide-like diuretic 1
2. Increase to full dose 1
3. Add diuretic or ACE/ARB (whichever wasn't included initially) 1
4. If BP still uncontrolled, add spironolactone (or if not tolerated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker) 1

Special Considerations

• For resistant hypertension (uncontrolled on triple therapy), consider:

  • Replacing hydrochlorothiazide with chlorthalidone, which provides greater 24-hour BP reduction 7
  • Adding spironolactone as a fourth agent, which can provide an additional BP reduction of approximately 25/12 mmHg 7

• For elderly patients (>80 years) or frail individuals:

  • Consider monotherapy initially 1
  • Individualize BP targets based on frailty 1

• For medication optimization:

  • Simplify regimen with once-daily dosing and single-pill combinations when possible 1
  • Consider taking at least one antihypertensive medication at bedtime to improve 24-hour BP control 7

Monitoring and Follow-up

• Target BP reduction of at least 20/10 mmHg, ideally to <130/80 mmHg 1
• Aim to achieve target BP within 3 months of treatment initiation 1
• Check serum electrolytes and renal function within 1 month of adding or increasing the dose of diuretics or ACE inhibitors 7
• Monitor for potential adverse effects of medications, particularly electrolyte abnormalities with diuretics 8

Important Caveats

• Avoid combining an ACE inhibitor with an ARB due to increased risk of hyperkalemia and renal dysfunction without additional BP benefit 7
• For patients on losartan, the usual starting dose is 50 mg once daily, which can be increased to a maximum of 100 mg once daily as needed 9
• For patients with hepatic impairment, start losartan at a lower dose of 25 mg once daily 9
• Use caution with thiazide diuretics in patients with a history of gout due to potential for hyperuricemia 8
• Diuretics should be used with caution during pregnancy and only when edema is due to pathological causes 10