What is the recommended treatment for hypertension in adults?

Recommended Treatment for Hypertension in Adults

For most adults aged 60 years or older with hypertension, initiate pharmacologic treatment when systolic blood pressure is ≥150 mm Hg with a target of <150 mm Hg, using thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers as first-line agents, combined with lifestyle modifications including the DASH diet, sodium restriction, regular physical activity, and weight management. 1

Blood Pressure Targets by Age and Risk Profile

Adults ≥60 Years Old

• Primary target: SBP <150 mm Hg for general population to reduce mortality (absolute risk reduction 1.64%), stroke (ARR 1.13%), and cardiac events (ARR 1.25%) 1
• Consider more intensive target of SBP <140 mm Hg for patients with:
  • History of stroke or transient ischemic attack (moderate-quality evidence) 1
  • High cardiovascular risk based on individualized assessment (low-quality evidence) 1

Adults <65 Years Old

• Target: SBP/DBP <130/80 mm Hg for most patients 1
• Initiate pharmacologic therapy at SBP ≥130 mm Hg when 10-year ASCVD risk is ≥10% 1
• For stage 1 hypertension (SBP 130-139 or DBP 80-89 mm Hg) with ASCVD risk <10%, begin with lifestyle modifications alone and reassess in 3-6 months 1

Important caveat: The 2017 ACP/AAFP guideline 1 recommends higher targets (SBP <150 mm Hg) for older adults based on strong evidence, while the 2017 ACC/AHA guideline 1 recommends lower targets (SBP <130 mm Hg) for all adults. The ACP/AAFP approach prioritizes avoiding treatment-related harms in older adults, while ACC/AHA emphasizes cardiovascular event reduction. For older adults ≥60 years, the <150 mm Hg target is supported by stronger evidence (high-quality) for mortality reduction, while the <140 mm Hg target has only weak recommendations with lower quality evidence. 1

First-Line Pharmacologic Therapy

Medication Classes (All Equally Effective First-Line Options)

• Thiazide or thiazide-like diuretics (chlorthalidone or hydrochlorothiazide) 1, 2
• ACE inhibitors (e.g., enalapril) 1, 2
• Angiotensin receptor blockers (ARBs) (e.g., candesartan) 1, 2
• Calcium channel blockers (e.g., amlodipine) 1, 2

Treatment Algorithm for Stage 2 Hypertension (SBP ≥140 mm Hg)

• Initiate combination therapy with 2 agents from different classes at treatment onset 1
• Evaluate within 1 month and adjust as needed 1

Treatment Algorithm for Very High BP (SBP ≥180 or DBP ≥110 mm Hg)

• Prompt evaluation and immediate antihypertensive treatment required 1
• Assess for acute target organ damage to determine urgency of treatment 1

Essential Lifestyle Modifications (All Patients)

Dietary Interventions

• DASH diet (Dietary Approaches to Stop Hypertension) - most effective dietary intervention for BP reduction 3, 2
• Sodium restriction to <2 g/day - can reduce BP and potentially allow medication discontinuation in 40% when combined with weight loss 4, 2
• Potassium supplementation through diet (unless contraindicated) 2
• Limit alcohol to ≤2 standard drinks/day for men, ≤1 for women (maximum 14/week for men, 9/week for women) 5

Physical Activity

• 50-60 minutes of moderate-intensity aerobic exercise 3-4 times per week (brisk walking, cycling, swimming) 6
• Moderate intensity more effective than vigorous exercise for BP reduction 6
• Reduces SBP by approximately 5-8 mm Hg 7

Weight Management

• Achieve and maintain healthy body mass index 2, 5
• Weight loss enhances medication efficacy 3

Additional Considerations

• Smoking cessation (improves overall cardiovascular risk) 3
• Stress management for appropriately selected hypertensive patients 5

Special Populations

Diabetes Mellitus

• Initiate treatment at BP ≥130/80 mm Hg with target <130/80 mm Hg 1
• All first-line agents (diuretics, ACE inhibitors, ARBs, CCBs) are effective 1
• Consider ACE inhibitors or ARBs in presence of albuminuria 1

Post-Stroke/TIA

• Restart antihypertensive treatment after first few days of index event 1
• Target SBP <140 mm Hg to reduce recurrent stroke risk 1
• Preferred agents: thiazide diuretic, ACE inhibitor, ARB, or combination of thiazide plus ACE inhibitor 1

Monitoring Strategy

Follow-Up Intervals

• Stage 1 hypertension with low ASCVD risk: Reassess in 3-6 months after lifestyle modifications 1
• Stage 1 hypertension with high ASCVD risk or Stage 2: Reassess in 1 month after initiating treatment 1
• After medication changes: Follow up within 2-4 weeks 4
• Target achievement timeframe: Within 3 months 4

Measurement Techniques

• Use validated BP devices with appropriate cuff size 4
• Average ≥2 readings on ≥2 occasions before diagnosing hypertension 1
• Consider home BP monitoring to confirm diagnosis and assess treatment efficacy 4
• Assess for orthostatic hypotension in adults ≥60 years (measure BP sitting and standing) 4

Common Pitfalls to Avoid

• Therapeutic inertia: Do not continue ineffective monotherapy when combination therapy is indicated 8
• White coat hypertension: Confirm diagnosis with home or ambulatory BP monitoring before initiating treatment in low-risk patients 1
• Medication adherence: Use once-daily dosing and combination pills to improve adherence 1
• Orthostatic hypotension in elderly: Monitor for supine-to-standing BP decrease ≥20 mmHg systolic or ≥10 mmHg diastolic 4
• Excessive BP lowering: Avoid overly aggressive treatment causing symptomatic hypotension, especially in frail elderly 8