What are the newest guidelines for treating stage 1 hypertension?

Treatment Guidelines for Stage 1 Hypertension

For stage 1 hypertension (130-139/80-89 mmHg), initiate pharmacological therapy immediately only if the patient has high cardiovascular risk (≥10% 10-year ASCVD risk, diabetes, chronic kidney disease, or established cardiovascular disease); otherwise, start with lifestyle modifications alone for 3-6 months before considering medication. 1, 2

Risk Stratification Determines Treatment Approach

The 2017 ACC/AHA guidelines fundamentally changed hypertension management by incorporating absolute cardiovascular risk into treatment decisions rather than relying solely on blood pressure thresholds. 1

High-Risk Patients (Immediate Pharmacotherapy)

Start both lifestyle modifications AND medication immediately if the patient has: 1, 2

• ≥10% 10-year ASCVD risk (calculated using ACC/AHA Pooled Cohort Equations) 1
• Diabetes mellitus 1, 2
• Chronic kidney disease 1, 2
• Established cardiovascular disease 1, 2
• Age ≥65 years 1

For these high-risk patients, the treatment threshold is ≥130/80 mmHg, and the target is <130/80 mmHg. 1, 2

Low-Risk Patients (Lifestyle Modifications First)

For patients WITHOUT the above high-risk features, prescribe lifestyle modifications alone for 3-6 months before initiating pharmacotherapy. 1, 2 Reassess blood pressure every 3-6 months during this period. 1

Important caveat: If blood pressure remains ≥140/90 mmHg after the lifestyle modification trial period, initiate pharmacological therapy regardless of cardiovascular risk. 1, 2

Lifestyle Modifications (All Patients)

Implement the following evidence-based interventions: 1

• Sodium restriction to <1,500 mg/day (or reduce by at least 1,000 mg/day) 1
• Potassium supplementation to 3,500-5,000 mg/day 1
• Weight loss if overweight/obese (target ≥1 kg reduction) 1
• Physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise, OR 3 sessions/week of isometric resistance training 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1
• DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy, with reduced saturated and total fat 1

First-Line Pharmacological Therapy

When medication is indicated, choose from four equally effective first-line classes: 2, 3

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

Selection Based on Patient Characteristics

Black patients: Prefer calcium channel blockers or thiazide diuretics over ACE inhibitors/ARBs as monotherapy (more effective in this population). 2

Patients with albuminuria: ACE inhibitor or ARB is mandatory first-line choice—these agents reduce proteinuria and slow kidney disease progression beyond blood pressure lowering alone. 2

Patients with coronary artery disease: Select ACE inhibitor or ARB as first-line therapy. 2

Patients with chronic kidney disease: RAS inhibitors (ACE inhibitors or ARBs) are first-line because they reduce albuminuria and slow CKD progression. 2

Blood Pressure Targets

• Adults <65 years: <130/80 mmHg 2, 3
• Adults ≥65 years: Systolic <130 mmHg (diastolic target not specified in most recent guidelines) 2
• Frail elderly: Consider individualized target up to <140/80 mmHg based on frailty status 2

Monitoring Requirements

After initiating or changing medication: 2

• Follow-up in 7-14 days to assess response and adverse effects
• Monitor serum creatinine and potassium when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists
• Goal: Achieve blood pressure target within 3 months

During lifestyle modification trial: 1

• Reassess blood pressure every 3-6 months
• Consider home blood pressure monitoring or ambulatory blood pressure monitoring to confirm office readings

Critical Pitfalls to Avoid

Never combine ACE inhibitors with ARBs—this increases adverse effects (hyperkalemia, acute kidney injury) without additional cardiovascular benefit and is potentially harmful. 2

ACE inhibitors and ARBs are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential not using reliable contraception. 2

Do not delay treatment in high-risk stage 1 hypertensive patients—the absolute cardiovascular risk reduction is greater in high-risk individuals, making immediate treatment both clinically beneficial and cost-effective. 1, 2

Transition to Stage 2 Hypertension Management

If blood pressure is ≥140/90 mmHg (stage 2 hypertension), initiate two antihypertensive medications from different classes immediately, combined with lifestyle modifications, regardless of cardiovascular risk. 2 This approach is more effective than sequential monotherapy titration when blood pressure is >20/10 mmHg above goal. 1