What are the guidelines for managing hypertension?

Hypertension Management Guidelines

Diagnosis and Blood Pressure Measurement

Blood pressure should be measured with a validated device, patient seated with arm at heart level, taking at least two measurements per visit to confirm diagnosis before initiating treatment. 1, 2

• Ambulatory blood pressure monitoring (ABPM) is indicated when:

  • Clinic BP shows unusual variability 3
  • Suspected white coat hypertension (office readings elevated but patient asymptomatic) 3, 1
  • Hypertension resistant to three or more drugs 3
  • Symptoms suggest hypotension 3
  • ABPM readings are typically 10/5 mmHg lower than office equivalents 3, 4

• Routine investigations must include: 3, 1

  • Urine dipstick for blood and protein
  • Serum electrolytes and creatinine
  • Blood glucose
  • Serum total:HDL cholesterol ratio
  • 12-lead ECG
  • Formal 10-year cardiovascular disease risk assessment 1

Treatment Thresholds

Initiate drug treatment immediately for all patients with sustained BP ≥160/100 mmHg regardless of other factors. 3, 1

• For BP 140-159/90-99 mmHg, start pharmacotherapy if any of the following: 3, 1

  • Target organ damage present
  • Established cardiovascular disease
  • Diabetes mellitus
  • 10-year cardiovascular disease risk ≥20%

• Urgent treatment required for: 3, 4

  • Accelerated hypertension (severe BP with grade III-IV retinopathy)
  • BP >220/120 mmHg
  • Impending complications (transient ischemic attack, left ventricular failure)

Blood Pressure Targets

For most patients, target BP is ≤140/85 mmHg, but patients with diabetes, chronic kidney disease, or established cardiovascular disease require a lower target of ≤130/80 mmHg. 3, 1, 4

• The European Society of Cardiology recommends even lower default targets of 120-129/70-79 mmHg for most patients, though this represents a more aggressive approach 2
• Evidence from the HOT trial showed optimal BP for cardiovascular event reduction was 139/83 mmHg, with no harm from lower pressures 3
• When using ABPM, subtract approximately 10/5 mmHg from office BP targets 3, 1

Lifestyle Modifications (First-Line for All Patients)

All patients with hypertension or high-normal BP must receive intensive lifestyle counseling, which can be implemented for up to 6 months in grade 1 hypertension without complications before adding medications. 3, 1

• Weight reduction to ideal body mass index through reduced fat and calorie intake 3, 5
• Regular physical activity emphasizing dynamic exercise (brisk walking) rather than isometric (weight training) 3, 5
• Sodium restriction: eliminate excessively salty foods, limit salt when preparing food 3, 5
• Alcohol limitation: <21 units/week for men, <14 units/week for women 3, 6
• Dietary pattern: increased fruit, vegetables, and low-fat dairy products (DASH diet approach) 3, 7
• Smoking cessation for additional cardiovascular risk reduction 3, 2

Common pitfall: Lifestyle modifications should continue even after starting medications, as they enhance drug efficacy and may reduce required doses 3, 5

Pharmacological Management

First-line drug therapy consists of thiazide or thiazide-like diuretics (chlorthalidone, hydrochlorothiazide), ACE inhibitors or ARBs (lisinopril, candesartan), and calcium channel blockers (amlodipine). 1, 8, 9, 5

Initial Drug Selection

• For most patients with confirmed hypertension (≥140/90 mmHg), combination therapy is recommended as initial treatment 4, 2
• Preferred initial combinations: RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker OR a thiazide diuretic 4, 2
• Fixed-dose single-pill combinations improve adherence 2
• Beta-blockers are not first-line unless specific compelling indications exist 1

Titration Strategy

• Titrate medications every 1-3 months until BP controlled, ideally achieving target within 3 months 2
• If BP remains uncontrolled on two drugs, add a third agent from a different class 1
• For resistant hypertension (≥3 drugs), consider adding mineralocorticoid receptor antagonist (spironolactone) as fourth agent 10

Common pitfall: Inadequate dosing is a frequent cause of apparent treatment resistance—ensure medications are at optimal doses before adding additional agents 1, 10

Special Populations and Considerations

High-Risk Patients (Diabetes, CKD, Established CVD)

• Target BP ≤130/80 mmHg 3, 1, 4
• More aggressive treatment warranted due to higher absolute cardiovascular risk 5

Elderly Patients (≥80-85 years)

• Continue treatment if well tolerated 4, 2
• May use more relaxed targets in those with orthostatic hypotension or moderate-to-severe frailty 2

Suspected Secondary Hypertension (Requires Specialist Referral)

• Red flags requiring investigation: 3, 1
  • Young age (<30 years requiring treatment, any hypertension <20 years)
  • Sudden onset or worsening of hypertension
  • Resistant to ≥3 drugs at optimal doses
  • Hypokalemia with elevated/high-normal sodium (suggests Conn's syndrome)
  • Elevated serum creatinine
  • Proteinuria or hematuria

Pregnancy

• Requires specialized management—refer to obstetric guidelines 3, 1

Monitoring and Follow-Up

• Regular BP monitoring using both office and home readings when possible 1, 4
• Annual cardiovascular risk reassessment 1, 4
• Monitor for medication adverse effects and adjust therapy accordingly 1
• Encourage medication adherence by establishing convenient dosing patterns 4

Common pitfall: Failing to confirm elevated readings with multiple measurements before diagnosis leads to overtreatment of white coat hypertension 3, 1