What are the guidelines for treating hypertension?

From the Guidelines

Blood pressure treatment guidelines recommend initiating medication when blood pressure consistently exceeds 140/90 mmHg, or 130/80 mmHg for those with diabetes, kidney disease, or high cardiovascular risk, as stated in the 2022 World Health Organization guideline executive summary 1.

Key Recommendations

• First-line medications include thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers, with treatment typically starting with a single medication at a low dose, increasing as needed 1.
• Lifestyle modifications are essential alongside medication, including reducing sodium intake, regular exercise, limiting alcohol, maintaining healthy weight, and following a DASH diet rich in fruits, vegetables, and low-fat dairy.
• The 2022 WHO guideline provides the most current and relevant evidence-based guidance for pharmacological treatment of hypertension in non-pregnant adults, with a particular focus on practice in middle- and low-income countries 1.

Medication Options

• Thiazide diuretics, such as hydrochlorothiazide 12.5-25 mg daily
• ACE inhibitors, such as lisinopril 10-40 mg daily
• ARBs, such as losartan 50-100 mg daily
• Calcium channel blockers, such as amlodipine 5-10 mg daily

Important Considerations

• Regular blood pressure monitoring is crucial, with a target of below 130/80 mmHg for most adults 1.
• The choice of medication and treatment target should be individualized based on patient characteristics and comorbidities, as recommended by the American College of Physicians and American Academy of Family Physicians 1.
• The 2022 WHO guideline emphasizes the importance of accurate blood pressure measurement and the use of single-pill combination medications to improve adherence and outcomes 1.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

The blood pressure treatment guidelines recommend comprehensive cardiovascular risk management, including:

• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake It is also stated that many patients will require more than one drug to achieve blood pressure goals, and that specific advice on goals and management can be found in published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 2, 3, 4.

From the Research

Blood Pressure Treatment Guidelines

• The decision to initiate antihypertensive medication should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 5.
• First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 5, 6.
• First-line drug therapy for hypertension consists of a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker 5, 6.
• The target blood pressure is less than 130/80 mm Hg for adults under 65 years and less than 130 mm Hg for adults 65 years and older 5.
• Randomized clinical trials have established the efficacy of blood pressure lowering to reduce the risk of cardiovascular disease morbidity and mortality, with an systolic blood pressure reduction of 10 mm Hg decreasing the risk of cardiovascular disease events by approximately 20% to 30% 5.
• Angiotensin-converting enzyme inhibitors are indicated for treatment of patients at high risk for coronary artery disease, after myocardial infarction, with dilated cardiomyopathy, or with chronic kidney disease 7.
• The use of angiotensin-converting enzyme inhibitors can be limited by idiosyncratic reactions, hyperkalemia, or hypotension 7.
• Triple fixed-dose combination therapy with an angiotensin II receptor blocker, a calcium channel blocker, and a thiazide diuretic is a rational combination for patients who require multiple medications to achieve blood pressure control 8.
• Angiotensin receptor blockers have equal outcome efficacy to angiotensin-converting enzyme inhibitors but with fewer adverse events, making them a viable alternative for the treatment of hypertension 9.