What are the guidelines for managing Hypertension (HTN)?

Hypertension Management Guidelines

Diagnosis and Blood Pressure Measurement

Blood pressure should be measured using a validated device with the patient seated, arm at heart level, taking at least two measurements at each visit to confirm diagnosis before initiating treatment. 1

• Ambulatory blood pressure monitoring (ABPM) is indicated when you suspect white coat hypertension, observe unusual BP variability, or encounter resistant hypertension; expect values approximately 10/5 mmHg lower than office readings. 1, 2
• Home blood pressure monitoring (HBPM) is the most practical method for documenting BP during medication titration and is more sensitive than office readings for detecting masked hypertension. 1
• Routine investigations must include urine testing for blood and protein, blood electrolytes and creatinine, blood glucose, serum cholesterol, and 12-lead ECG. 1, 2
• Formal estimation of 10-year cardiovascular disease risk should guide all treatment decisions. 1, 2

Treatment Thresholds

Initiate antihypertensive drug therapy immediately if sustained systolic BP ≥160 mmHg or sustained diastolic BP ≥100 mmHg, even without other risk factors. 3, 1

• For sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg, start drug treatment if any of the following are present: 3, 1
  • Target organ damage
  • Established cardiovascular disease
  • Diabetes mellitus
  • 10-year cardiovascular disease risk ≥20%

Urgent Treatment Required

Immediate treatment is needed for: 3

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

Blood Pressure Targets

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

• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, target BP is <130/80 mmHg (audit standard <140/80 mmHg). 3, 1, 2
• When using ambulatory or home BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents. 3, 2
• The evidence supports a "lower the better" policy for optimal blood pressure in higher-risk populations (diabetes, post-stroke, high cardiovascular risk). 3

Lifestyle Modifications

All patients with hypertension, borderline, or high-normal blood pressure must receive lifestyle modification recommendations, which can lower systolic BP by approximately 5 mmHg per intervention. 1, 2

Specific Interventions with Proven Efficacy:

• DASH diet (emphasizing fruits, vegetables, whole grains, low-fat dairy products, with reduced saturated and total fat) reduces SBP by ~5 mmHg. 1
• Sodium restriction with optimal goal <1500 mg/day reduces SBP by 1-3 mmHg per 1000 mg decrease in sodium intake. 1
• Weight loss to achieve ideal body weight reduces SBP by approximately 1 mmHg for every 1 kg weight loss. 1
• Physical activity (aerobic exercise 5-7 times/week for 30-60 minutes/session) reduces SBP by ~5 mmHg. 1
• Alcohol moderation (men ≤2 standard drinks/day, women ≤1 standard drink/day) reduces SBP by ~4 mmHg. 1
• Potassium supplementation with optimal goal 3500-5000 mg/day reduces SBP by ~5 mmHg. 1

Timing of Lifestyle Intervention:

• For patients with grade 1 (mild) hypertension (140-159/90-99 mmHg) and no complications or target organ damage, evaluate lifestyle measures alone for up to six months before adding pharmacotherapy. 3
• For those requiring antihypertensive drugs, continue lifestyle measures as they complement BP-lowering effects and may reduce the dose or number of drugs required. 3

Pharmacological Management

Most patients with hypertension will require at least two blood pressure lowering drugs to achieve recommended goals; fixed-dose combinations are preferred when no cost disadvantages exist. 1

Initial Drug Selection:

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. 1

• Chlorthalidone is the preferred thiazide-like diuretic. 1
• Amlodipine is the first-line calcium channel blocker. 1
• First-line agents include thiazide or thiazide-like diuretics, ACE inhibitors or ARBs, calcium channel blockers, and beta-blockers (in patients <60 years). 2, 4

Medication Timing:

• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence. 1, 5

Adjunctive Therapy for Cardiovascular Risk Reduction

Aspirin is recommended for primary prevention in patients ≥50 years with BP controlled to <150/90 mmHg and target organ damage, diabetes, or 10-year CVD risk ≥20%. 1

Statins are recommended for primary prevention in patients up to at least 80 years with 10-year CVD risk ≥20% and total cholesterol ≥3.5 mmol/L. 1

• The target for statin therapy is to 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. 1

Secondary Hypertension Evaluation

Suspect secondary hypertension and investigate further when: 3, 2

• Hypokalaemia with increased or high normal plasma sodium (suggesting Conn's syndrome)
• Elevated serum creatinine
• Proteinuria or haematuria
• Sudden onset or worsening of hypertension
• Resistant to multidrug regimen (≥3 drugs)
• Young age (any hypertension <20 years; needing treatment <30 years)

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis. 2
• Not considering white coat hypertension when office readings are elevated but patient appears otherwise low-risk. 2
• 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, CKD, or established CVD. 2
• 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. 1, 2

• Annual reassessment of cardiovascular risk is recommended. 1, 2
• Monitor for adverse effects of medications and adjust therapy as needed. 1, 2