What are the guidelines for managing hypertension?

Hypertension Management Guidelines

For most patients with hypertension, initiate drug therapy when sustained BP is ≥160/100 mmHg, or ≥140/90 mmHg if target organ damage, established cardiovascular disease, diabetes, or 10-year CVD risk ≥20% is present, targeting <140/85 mmHg for most patients and <130/80 mmHg for those with diabetes, renal impairment, or established CVD. 1, 2, 3

Blood Pressure Measurement and Diagnosis

Proper measurement technique is essential to avoid misdiagnosis:

• Measure BP with a validated device, patient seated with arm at heart level, cuff deflated at 2 mm/s, recording to the nearest 2 mm Hg 1, 2
• Diastolic pressure is recorded as disappearance of sounds (phase V) 1
• Take at least two measurements at each of several visits before confirming diagnosis 1, 2, 3

Ambulatory blood pressure monitoring (ABPM) is indicated for: 1, 2, 3

• Unusual clinic BP variability
• Resistant hypertension (≥3 drugs)
• Suspected white coat hypertension
• Symptoms suggesting hypotension

When using ambulatory or home BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents 1, 2, 3

Initial Evaluation

All hypertensive patients require routine investigations: 1, 2, 3

• Urine strip test for blood and protein
• Blood electrolytes and creatinine
• Blood glucose
• Serum total:HDL cholesterol ratio
• 12-lead electrocardiograph

Calculate 10-year cardiovascular disease risk to guide treatment decisions 2, 3

Treatment Thresholds

Urgent treatment is needed for: 1, 2

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

Standard treatment thresholds: 1, 2, 3

• Start drug therapy for all patients with sustained BP ≥160/100 mmHg despite lifestyle measures
• Start drug therapy for BP 140-159/90-99 mmHg if any of the following:
  • Target organ damage present
  • Established cardiovascular disease
  • Diabetes mellitus
  • 10-year CVD risk ≥20%

For BP 140-159/90-99 mmHg without these risk factors, evaluate lifestyle measures for up to 6 months before initiating drug therapy 1

Blood Pressure Targets

For most non-diabetic patients, target BP <140/85 mmHg (minimum acceptable audit standard <150/90 mmHg) 1, 2, 3

For patients with diabetes, chronic kidney disease, or established cardiovascular disease, target BP <130/80 mmHg 1, 2, 3

The more recent evidence supports a "lower is better" approach for high-risk populations, though the HOT trial showed patients between 139/83 mmHg and 150/90 mmHg were not disadvantaged 1

Lifestyle Modifications

All patients with hypertension, borderline, or high-normal BP should receive lifestyle modification recommendations 1, 2, 3, 4

Evidence-based interventions that lower BP: 1, 3, 4, 5, 6

• Weight reduction: Achieve ideal body weight through reduced fat and total calorie intake; approximately 1 mmHg reduction per 1 kg weight loss 3
• Physical activity: Regular aerobic exercise 5-7 times/week for 30-60 minutes/session; predominantly dynamic (brisk walking) rather than isometric (weight training); reduces SBP by ~5 mmHg 1, 3
• Alcohol moderation: Men ≤2 standard drinks/day, women ≤1 standard drink/day; reduces SBP by ~4 mmHg 3
• Sodium restriction: Optimal goal <1500 mg/day; reduces SBP by 1-3 mmHg per 1000 mg decrease 3, 6
• Potassium supplementation: Optimal goal 3500-5000 mg/day; reduces SBP by ~5 mmHg 3, 6
• DASH diet: Emphasizes fruits, vegetables, low-fat dairy products, whole grains, nuts, fish, and poultry; reduced in saturated fats, red meats, sweets, and sugar-containing beverages; reduces SBP by ~5 mmHg 3, 4, 6, 7

Additional cardiovascular risk reduction measures: 1

• Smoking cessation
• Reduce total and saturated fat intake
• Replace saturated fats with monounsaturated fats (olive oil, rapeseed oil)
• Increase consumption of oily fish

These lifestyle measures complement drug therapy and may reduce the dose or number of drugs required 1

Pharmacological Management

Most patients will require at least two BP-lowering drugs to achieve recommended goals; fixed-dose combinations are preferred when no cost disadvantages exist 3

First-line drug therapy consists of: 1, 3, 8, 9, 4

• Thiazide or thiazide-like diuretics (chlorthalidone preferred) 3, 4
• ACE inhibitors (e.g., lisinopril, enalapril) or angiotensin receptor blockers (ARBs) (e.g., candesartan) 8, 4
• Calcium channel blockers (amlodipine as first-line) 3, 9, 4

Fixed-dose combinations, preferably combining a renin-angiotensin system (RAS) blocker with either a dihydropyridine calcium channel blocker or thiazide-like diuretic, are recommended as initial therapy 3

When no compelling indications exist, initial drug selection should follow the AB/CD algorithm 1, 2

Compelling indications for specific drug classes: 1

• ACE inhibitors: Heart failure, left ventricular dysfunction post-MI, established coronary heart disease, type 1 diabetic nephropathy, type 2 diabetic nephropathy, chronic renal disease, secondary stroke prevention 1
• ARBs: ACE inhibitor intolerance, type 2 diabetic nephropathy, left ventricular dysfunction after MI 1
• Alpha-blockers: Benign prostatic hypertrophy 1

Compelling contraindications: 1

• ACE inhibitors/ARBs: Pregnancy, renovascular disease 1
• Alpha-blockers: Urinary incontinence 1

Lowering BP reduces cardiovascular events regardless of drug class; an SBP reduction of 10 mmHg decreases CVD events by approximately 20-30% 8, 9, 4

Adjunctive Cardiovascular Risk Reduction

For patients ≥50 years with BP controlled to <150/90 mmHg and target organ damage, diabetes, or 10-year CVD risk ≥20%, consider aspirin for primary prevention 3

For patients up to at least 80 years with 10-year CVD risk ≥20% and total cholesterol ≥3.5 mmol/L, initiate statin therapy 3

Target for statin therapy: lower total cholesterol by 25% or LDL cholesterol by 30%, or reach <4.0 mmol/L or <2.0 mmol/L respectively, whichever is greater 3

Specialist Referral Indications

Refer to specialist for: 1, 2

• Malignant hypertension or impending complications
• Suspected secondary causes: hypokalaemia with increased/high-normal plasma sodium (Conn's syndrome), elevated serum creatinine, proteinuria or haematuria, sudden onset or worsening of hypertension
• Resistant hypertension (≥3 drugs)
• Young age (any hypertension <20 years; needing treatment <30 years)
• Unusual BP variability or possible white coat hypertension
• Pregnancy

Common Pitfalls to Avoid

Critical errors that compromise hypertension management: 2, 3

• Failing to confirm elevated readings with multiple measurements at multiple visits before diagnosis 2, 3
• Not considering white coat hypertension when office readings are elevated 2, 3
• Inadequate dosing or inappropriate combinations of antihypertensive medications 2
• Not addressing lifestyle modifications alongside pharmacological treatment 2
• Overlooking the need for lower BP targets (<130/80 mmHg) in high-risk patients with diabetes, chronic kidney disease, or established CVD 1, 2, 3
• Not considering secondary causes in resistant hypertension or young patients 2

Monitoring and Follow-up

Regular BP monitoring using both office and home readings is necessary for optimal management 2, 3

Annual reassessment of cardiovascular risk is recommended 2, 3

Monitor for adverse effects of medications and adjust therapy as needed 2, 3

Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence 3

Despite the benefits of BP control, only 44% of US adults with hypertension have their BP controlled to <140/90 mmHg, highlighting the need for aggressive implementation of these guidelines 4