What are the guidelines for managing hypertension?

Guidelines for Hypertension Management

All hypertensive patients should receive lifestyle modifications alongside pharmacological therapy when indicated, with treatment thresholds and targets determined by blood pressure levels, cardiovascular risk, and presence of target organ damage or comorbidities.

Diagnosis and Blood Pressure Measurement

Proper measurement technique is essential to avoid misdiagnosis:

• Measure blood pressure with a validated device, patient seated with arm at heart level, cuff appropriately sized for arm circumference, deflated at 2 mm/s, recorded to nearest 2 mm Hg 1, 2
• Take at least two measurements at each of several visits before establishing diagnosis 1, 2
• Diastolic pressure is recorded as disappearance of sounds (phase V) 1

Ambulatory blood pressure monitoring (ABPM) is indicated for: 1, 2

• Unusual blood pressure variability
• Suspected white coat hypertension
• Resistant hypertension (≥3 drugs)
• Symptoms suggesting hypotension
• When using ABPM or home readings, expect values approximately 10/5 mm Hg lower than office readings 1, 3

Initial Evaluation

All hypertensive patients require routine investigations to assess: 1, 2

• Urine strip test for blood and protein
• Blood electrolytes and creatinine
• Blood glucose
• Serum total:HDL cholesterol ratio
• 12-lead electrocardiogram
• Formal 10-year cardiovascular disease risk estimation 2

Specialist referral is indicated for: 1

• Urgent situations: malignant hypertension (grade III-IV retinopathy), severe hypertension >220/120 mm Hg, impending complications
• Suspected secondary causes: hypokalaemia with elevated sodium, elevated creatinine, proteinuria/haematuria, sudden onset or worsening, resistance to ≥3 drugs, young age (<30 years needing treatment)
• Pregnancy-related hypertension

Treatment Thresholds for Drug Therapy

Start antihypertensive medications based on this algorithm:

• Immediate treatment: All patients with sustained BP ≥160/100 mm Hg regardless of cardiovascular risk 1, 2
• Conditional treatment (BP 140-159/90-99 mm Hg): Treat if ANY of the following present 1, 2:
  • Target organ damage
  • Established cardiovascular disease
  • Diabetes mellitus
  • 10-year cardiovascular disease risk ≥20%

For BP 140-159/90-99 mm Hg without the above conditions: Evaluate lifestyle modifications for up to 6 months before initiating drug therapy 1

Blood Pressure Targets

Target blood pressure varies by patient risk profile:

• Standard target: <140/85 mm Hg for most patients 1, 2, 3
• Intensive target: <130/80 mm Hg for patients with diabetes, renal impairment, or established cardiovascular disease 1, 2, 3
• The optimal blood pressure for cardiovascular event reduction is 139/83 mm Hg, with no harm from lowering below this level 1
• Patients maintaining BP between 139/83 and 150/90 mm Hg are not disadvantaged 1

Common pitfall: Failing to use lower targets in high-risk patients (diabetes, chronic kidney disease, established cardiovascular disease) increases their cardiovascular morbidity and mortality 2, 3

Lifestyle Modifications

Recommend these evidence-based interventions to ALL hypertensive and prehypertensive patients: 1, 4

• Weight reduction: Achieve ideal body weight through reduced fat and total calorie intake; even 3-9% weight loss reduces BP by approximately 3 mm Hg 1, 5
• Physical activity: Regular dynamic exercise (brisk walking) rather than isometric (weight training); improves fitness and lowers BP 1, 4
• Alcohol limitation: <21 units/week for men, <14 units/week for women 1
• Sodium restriction: Reduce salt in food preparation, eliminate excessively salty foods; particularly effective in older adults, diabetics, and established hypertension 1, 5
• Dietary pattern: Increase fruits, vegetables, and low-fat dairy products (DASH diet); this can lower BP as effectively as some antihypertensive drugs 1, 4, 6
• Potassium and calcium: Adequate intake more important than sodium restriction alone 5
• Smoking cessation: Reduces overall cardiovascular risk 1

Implementation requires: Trained health professionals (practice/clinic nurse), patient and family education, clear written information, and 6-month trial in grade 1 hypertension without complications 1

Pharmacological Management

First-line antihypertensive agents include: 2, 3, 4

• Thiazide or thiazide-like diuretics (hydrochlorothiazide, chlorthalidone)
• ACE inhibitors (lisinopril) or angiotensin receptor blockers (ARBs) 7
• Calcium channel blockers (amlodipine) 8
• Beta-blockers (when compelling indications exist)

Combination therapy approach: 3

• Most patients require >1 drug to achieve BP goals 7, 8, 4
• Preferred combinations: RAS blocker (ACE inhibitor or ARB) with either dihydropyridine calcium channel blocker or diuretic 3
• Follow AB/CD algorithm when no compelling indications exist 2

Drug selection considerations: 7, 8, 4

• Some agents have smaller effects as monotherapy in Black patients
• Consider additional indications (angina, heart failure, diabetic kidney disease)
• Lisinopril indicated for hypertension, heart failure, and post-MI mortality reduction 7
• Amlodipine indicated for hypertension, chronic stable angina, and documented CAD 8

Medication timing: Take at most convenient time to establish habitual pattern and improve adherence 3

Resistant Hypertension

BP uncontrolled on ≥3 drugs requires systematic evaluation: 9

1. Rule out pseudoresistance: Poor measurement technique, white coat effect, medication non-adherence 2, 9
2. Identify interfering substances: NSAIDs, decongestants, excessive alcohol, illicit drugs 9
3. Screen for secondary causes: See specialist referral criteria above 9
4. Optimize regimen: Ensure appropriate doses, complementary mechanisms of action, appropriate diuretic included 9
5. Add mineralocorticoid receptor antagonist: Effective as fourth agent even without biochemical aldosterone excess 9

Hypertensive Emergencies

Severe hypertension with target organ damage requires: 1, 9

• Hypertensive emergency (with organ damage): Reduce BP within hours using parenteral agents 9
• Hypertensive urgency (without organ damage): Reduce BP within days using oral agents 9
• Accelerated hypertension: Grade III-IV retinopathy mandates urgent treatment 1

Monitoring and Follow-up

Ongoing management requires: 2, 3

• Regular BP monitoring with office and home readings when possible
• Annual cardiovascular risk reassessment
• Monitoring for medication adverse effects with therapy adjustment as needed
• Lifestyle modifications should continue alongside pharmacological treatment 1

Critical pitfall: Only 44% of US adults with hypertension achieve control to <140/90 mm Hg despite proven benefits of a 10 mm Hg SBP reduction decreasing cardiovascular events by 20-30% 4