What are the guidelines for managing hypertension?

Hypertension Management Guidelines

For adults with confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications and pharmacological therapy immediately, targeting a blood pressure of ≤130/80 mmHg for high-risk patients (diabetes, chronic kidney disease, established cardiovascular disease) and ≤140/85 mmHg for others. 1, 2

Blood Pressure Measurement and Diagnosis

Proper measurement technique is critical to avoid misdiagnosis:

• Measure BP with a validated device, patient seated with arm at heart level, using appropriate cuff size for arm circumference 3, 1
• Deflate cuff at 2 mm/s and record to nearest 2 mm Hg; diastolic pressure is recorded at disappearance of sounds (phase V) 3
• Obtain at least two measurements at each of several visits before confirming diagnosis 3, 2

Consider ambulatory blood pressure monitoring (ABPM) when: 3, 2

• Clinic BP shows unusual variability
• Suspected white coat hypertension (office readings elevated but patient asymptomatic)
• Hypertension resistant to three or more drugs
• Symptoms suggest hypotension despite elevated office readings

ABPM readings are typically 10/5 mmHg lower than office measurements and should be interpreted accordingly. 1

Classification and Treatment Thresholds

Hypertension stages determine urgency of intervention: 1, 2

• Normal: <120/80 mmHg - lifestyle counseling only
• Elevated/Prehypertension: 120-139/80-89 mmHg - intensive lifestyle modifications; consider pharmacotherapy if 10-year CVD risk ≥10% 4
• Stage 1: 140-159/90-99 mmHg - treat with medications if target organ damage, established CVD, diabetes, or 10-year CVD risk ≥20% present 2
• Stage 2: ≥160/100 mmHg - immediate pharmacological treatment for all patients 2
• Hypertensive urgency: ≥180/110 mmHg - urgent treatment required 1, 2

Initial Evaluation

All hypertensive patients require focused assessment to identify: 3, 2

• Routine investigations: Urinalysis for blood and protein, serum electrolytes and creatinine, blood glucose, total:HDL cholesterol ratio, 12-lead ECG 3, 2
• Target organ damage: Proteinuria, hematuria, elevated creatinine, ECG abnormalities
• Cardiovascular risk factors: Diabetes, dyslipidemia, smoking, family history
• 10-year cardiovascular disease risk calculation to guide treatment intensity 2

Refer to specialist when: 3

• Malignant hypertension or impending complications
• Suspected secondary hypertension (young age, sudden onset, resistant to multiple drugs, electrolyte abnormalities)
• Therapeutic failures despite appropriate treatment
• Pregnancy-related hypertension

Lifestyle Modifications

All patients with elevated BP or hypertension must receive comprehensive lifestyle counseling, which enhances medication efficacy and may prevent need for drugs in borderline cases: 3, 1, 5

Weight management:

• Achieve and maintain ideal body weight through reduced fat and total calorie intake 3
• Weight loss produces BP reductions comparable to single-drug therapy in overweight individuals 5, 6

Physical activity:

• Regular aerobic exercise (brisk walking preferred over isometric weight training) 3
• Improves fitness and independently lowers BP 6

Dietary modifications:

• Sodium restriction: Eliminate excessively salty foods; limit salt when preparing food 3, 5
• Increased potassium: Consume more fruits and vegetables 3
• DASH diet pattern: Emphasize fruits, vegetables, low-fat dairy products; reduce saturated fat 5, 6

Alcohol limitation:

• Men: <21 units per week 3
• Women: <14 units per week 3
• Moderation or elimination reduces BP significantly 5, 7

Smoking cessation: Essential for overall cardiovascular risk reduction 3, 8

These interventions have additive effects when combined and should be implemented by trained healthcare professionals with written patient education materials. 3, 6

Pharmacological Management

For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment: 1, 4

First-line agents include: 1, 2, 5

• Thiazide or thiazide-like diuretics (hydrochlorothiazide, chlorthalidone)
• ACE inhibitors (lisinopril) 9 or angiotensin receptor blockers (ARBs)
• Calcium channel blockers (amlodipine) 10

Preferred initial combinations: 1, 4

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker
• RAS blocker + thiazide diuretic
• Fixed-dose single-pill combinations improve adherence 4

Lowering BP reduces fatal and nonfatal cardiovascular events—primarily strokes and myocardial infarctions—with a 20-30% risk reduction for every 10 mmHg systolic BP decrease. 10, 9, 5

Treatment Targets

Target BP varies by patient risk profile: 1, 2

Standard target: ≤140/85 mmHg for most patients 1, 2

Intensive target: ≤130/80 mmHg for patients with: 1, 2

• Diabetes mellitus
• Chronic kidney disease (renal impairment)
• Established cardiovascular disease

Optimal target based on HOT trial: 139/83 mmHg showed best reduction in major cardiovascular events, with no harm from lower pressures 3

For elderly patients (≥80-85 years): Maintain treatment if well tolerated but consider more relaxed targets in those with orthostatic hypotension or moderate-to-severe frailty 4

Monitoring and Follow-up

After initiating treatment: 4

• See patients every 1-3 months until BP controlled
• Achieve control preferably within 3 months
• Utilize both office and home BP readings when possible 2, 4

Long-term management:

• Annual cardiovascular risk reassessment 1, 2
• Monitor for medication adverse effects and adjust therapy accordingly 2
• Medications should be taken at consistent times daily to establish routine and improve adherence 1

Common Pitfalls to Avoid

Diagnostic errors: 2

• Failing to confirm elevated readings with multiple measurements over several visits before diagnosis
• Not considering white coat hypertension when office readings are elevated but patient has no target organ damage

Treatment errors: 2

• Inadequate medication dosing or inappropriate drug combinations
• Not addressing lifestyle modifications alongside pharmacological treatment
• Overlooking need for lower BP targets in high-risk patients (diabetes, CKD, established CVD)
• Not investigating secondary causes in resistant hypertension or young patients with new-onset severe hypertension

Despite proven benefits of BP control, only 44% of US adults with hypertension achieve control to <140/90 mmHg, highlighting the importance of systematic, guideline-based management. 5