What are the guidelines for managing hypertension?

Hypertension Management Guidelines

Hypertension management requires a systematic approach starting with accurate diagnosis using multiple BP measurements, followed by cardiovascular risk stratification, lifestyle modifications for all patients, and pharmacological therapy with thiazide diuretics, ACE inhibitors/ARBs, or calcium channel blockers titrated to achieve BP targets of <140/85 mmHg for most patients or <130/80 mmHg for those with diabetes, renal disease, or established cardiovascular disease. 1, 2

Diagnosis and Blood Pressure Measurement

Proper BP measurement technique is essential to avoid misdiagnosis. The patient must be seated with the arm at heart level, using a validated device with appropriately sized cuff, deflating at 2 mm/s, measuring to the nearest 2 mmHg, with diastolic pressure recorded at disappearance of sounds (phase V). 3

• At least two measurements should be taken at each of several visits before establishing the diagnosis. 3, 1
• Ambulatory BP monitoring is indicated when clinic readings show unusual variability, when resistant hypertension is present (uncontrolled on three or more drugs), when symptoms suggest hypotension, or to diagnose white coat hypertension. 3, 1
• When using ambulatory or home BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents. 1, 2

Initial Evaluation

All hypertensive patients require a thorough history, physical examination, and specific routine investigations to assess cardiovascular risk, target organ damage, and secondary causes. 3, 1

Required baseline investigations include:

• Urine dipstick for blood and protein 3, 1
• Serum electrolytes and creatinine 3, 1
• Blood glucose 3, 1
• Serum total:HDL cholesterol ratio 3, 1
• 12-lead electrocardiogram 3, 1
• Formal estimation of 10-year cardiovascular disease risk 1

Treatment Thresholds

The decision to initiate drug therapy depends on both BP level and overall cardiovascular risk. 1, 4

• Urgent treatment is required for accelerated/malignant hypertension (BP ≥180/110 mmHg), severe hypertension with symptoms, or impending complications. 3, 1, 2
• Immediate drug therapy for all patients with sustained BP ≥160/100 mmHg. 1
• Drug therapy for BP 140-159/90-99 mmHg when any of the following are present: target organ damage, established cardiovascular disease, diabetes, or 10-year CVD risk ≥20%. 1, 2

Blood Pressure Targets

Target BP varies based on patient characteristics and comorbidities. 1, 2

• For most patients: BP target is ≤140/85 mmHg. 1, 2
• For high-risk patients (diabetes, renal impairment, or established cardiovascular disease): BP target is ≤130/80 mmHg. 1, 2
• The optimal BP for reduction of major cardiovascular events is approximately 139/83 mmHg, with no harm from lowering below this level. 3
• An SBP reduction of 10 mmHg decreases CVD event risk by approximately 20-30%. 4

Lifestyle Modifications

Lifestyle interventions should be recommended to all patients with hypertension and those with borderline or high-normal BP, as these measures lower BP and enhance medication efficacy. 3, 1, 4

Effective interventions include:

• Weight reduction to achieve ideal body weight through reduced fat and total calorie intake. 3, 1
• Regular physical activity that is predominantly dynamic (brisk walking) rather than isometric (weight training). 3, 1
• Dietary sodium restriction by reducing salt when preparing food and eliminating excessively salty foods. 3, 1, 4
• Increased potassium intake through consumption of fruits and vegetables. 3, 1, 4
• Alcohol limitation to <21 units/week for men and <14 units/week for women. 3, 1
• Smoking cessation to reduce overall cardiovascular risk. 3, 1
• Dietary pattern changes including increased consumption of fruits, vegetables, low-fat dairy products, and oily fish (DASH diet approach). 3, 4, 5

Pharmacological Management

First-line drug therapy consists of thiazide or thiazide-like diuretics, ACE inhibitors or ARBs, and calcium channel blockers. 1, 2, 6, 7, 4

Initial Drug Selection

• When no compelling indications exist, follow the AB/CD algorithm for drug selection. 1
• Combination therapy is increasingly recommended as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg). 2
• Preferred combinations include a renin-angiotensin system blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide diuretic. 2

Specific Agents

• Thiazide diuretics (hydrochlorothiazide or chlorthalidone) are effective first-line agents. 4
• ACE inhibitors (such as lisinopril) or ARBs (such as candesartan) are appropriate for most patients and particularly beneficial in diabetes, heart failure, and post-MI. 7, 4
• Calcium channel blockers (such as amlodipine) are effective as monotherapy or combination therapy. 6, 4
• Beta-blockers may be used when specific indications exist. 1

Medication Timing

• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence. 2

Resistant Hypertension

Resistant hypertension is defined as BP remaining uncontrolled despite use of three or more antihypertensive agents at optimal doses. 3, 8

Management approach:

• Rule out pseudoresistance (poor adherence, white coat effect, improper BP measurement). 8
• Screen for secondary causes of hypertension. 1, 8
• Ensure medications are prescribed at optimal doses using drugs with complementary mechanisms of action. 8
• Add an appropriate diuretic if not already included and no contraindications exist. 8
• Mineralocorticoid receptor antagonists are effective fourth-line agents, even without biochemical evidence of aldosterone excess. 8

Secondary Hypertension

Secondary causes should be suspected and investigated in specific clinical scenarios. 1

Indications for specialist referral and investigation:

• Elevated serum creatinine or proteinuria/hematuria 1
• Sudden onset or worsening of hypertension 1
• Young age at presentation 1
• Resistance to multiple drugs 3, 1
• Electrolyte abnormalities suggesting endocrine causes 1
• Unusually variable BP 3, 1
• Pregnancy 3, 1

Common Pitfalls to Avoid

• Diagnosing hypertension based on single elevated readings rather than confirming with multiple measurements over several visits. 1
• Not considering white coat hypertension when office readings are persistently elevated despite normal home readings. 1
• Inadequate medication dosing or using inappropriate drug combinations. 1
• Treating BP in isolation without addressing lifestyle modifications alongside pharmacological treatment. 1
• Using the same BP target for all patients rather than lowering targets to ≤130/80 mmHg in high-risk patients with diabetes, chronic kidney disease, or established CVD. 1, 2
• Failing to investigate secondary causes in resistant hypertension or young patients with severe hypertension. 1
• Measuring BP incorrectly with improper cuff size, patient positioning, or technique. 3, 1

Monitoring and Follow-up

• Regular BP monitoring using both office and home readings when possible is necessary. 1, 2
• Annual reassessment of cardiovascular risk is recommended. 1, 2
• Monitor for adverse effects of medications and adjust therapy as needed. 1, 2