What are the current guidelines for managing hypertension?

Current Hypertension Management Guidelines

The most recent 2024-2025 guidelines recommend initiating upfront combination therapy with single-pill combinations for most adults with confirmed hypertension, targeting a systolic blood pressure of 120-129 mmHg if well tolerated, which represents a significant shift toward more aggressive early treatment and lower targets than previous recommendations. 1, 2

Diagnosis and Blood Pressure Thresholds

Hypertension is diagnosed when:

• Office BP ≥140/90 mmHg (confirmed by home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg) 1, 2
• Measure BP in both arms at first visit and use the arm with higher readings for subsequent measurements 1, 2
• Use validated automated upper arm cuff devices with appropriate cuff size 1

Classification:

• Grade 1 Hypertension: 140-159/90-99 mmHg 1
• Grade 2 Hypertension: ≥160/100 mmHg 1

Note that the American College of Cardiology/American Heart Association uses lower thresholds (≥130/80 mmHg), but the International Society of Hypertension and European Society of Cardiology maintain the traditional ≥140/90 mmHg definition 2.

Lifestyle Modifications (First-Line for All Patients)

All patients with elevated BP or hypertension must implement lifestyle changes: 1, 2, 3

• Weight reduction to achieve ideal body weight 1, 3
• Dietary sodium restriction and increased potassium intake 1, 3
• DASH or Mediterranean diet (high in fruits, vegetables, low-fat dairy products) 1, 3, 4
• Physical activity: 150 minutes/week of moderate aerobic exercise 1, 3
• Alcohol limitation: <21 units/week for men, <14 units/week for women 1
• Smoking cessation 1

These lifestyle modifications have additive BP-lowering effects and enhance pharmacologic therapy efficacy 3.

Pharmacological Treatment Algorithm

When to Start Drug Therapy

Grade 2 Hypertension (≥160/100 mmHg):

• Start immediate drug treatment alongside lifestyle interventions for all patients 1

Grade 1 Hypertension (140-159/90-99 mmHg):

• High-risk patients: Start immediate drug treatment 1
• Low-moderate risk patients: Begin drug therapy after 3-6 months of lifestyle intervention if BP remains elevated 1

Initial Drug Selection

The 2024 guidelines recommend upfront combination therapy (preferably as single-pill combinations) for most adults to improve adherence and achieve faster BP control. 2

For Non-Black Patients:

• Start with low-dose ACE inhibitor or angiotensin receptor blocker (ARB) 1
• Increase to full dose if needed 1
• Add calcium channel blocker (CCB) or thiazide-like diuretic as second agent 1, 2, 3

For Black Patients:

• Start with low-dose ARB + dihydropyridine CCB OR dihydropyridine CCB + thiazide-like diuretic 1, 2
• Increase to full dose if needed 1
• CCBs and thiazide diuretics are more effective as initial therapy than RAS blockers in this population 1, 2

Treatment Escalation:

1. Start with low-dose combination therapy 2
2. Increase to full dose if BP remains uncontrolled 2
3. Add a third agent if still uncontrolled 2

Specific Drug Classes

First-line medications include: 1, 2, 3

• ACE inhibitors (e.g., enalapril) or ARBs (e.g., candesartan) 5, 3
• Calcium channel blockers (e.g., amlodipine) 6, 3
• Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide) 3

Beta-blockers:

• Use only when specific indications exist: coronary artery disease, heart failure, or heart rate control 1, 2
• Not recommended for general population hypertension treatment 2
• Caution when combining with thiazide diuretics due to increased diabetes risk 7

Blood Pressure Targets

For most patients <65 years:

• Target BP <130/80 mmHg 1, 3
• Optimal target: systolic BP 120-129 mmHg if well tolerated 1, 2

For patients ≥65 years:

• Target systolic BP <130 mmHg 3
• Individualize based on frailty 1

For patients ≥80 years or frail:

• Consider more lenient targets 2
• Start with lower doses and more gradual BP reduction 1

Achieve target BP within 3 months 1, 2

Aim to reduce BP by at least 20/10 mmHg from baseline 1

Special Populations

Diabetes:

• Target BP <130/80 mmHg 1, 3
• Treatment strategy should include RAS inhibitor plus CCB and/or thiazide-like diuretic 1

Chronic Kidney Disease:

• Target BP <130/80 mmHg 1
• Use RAS inhibitors as first-line therapy 1

Coronary Artery Disease:

• Consider beta-blockers and RAS inhibitors 1
• Avoid overaggressive diastolic BP reduction in patients with established ischemic heart disease 2

Established Cardiovascular Disease:

• Target BP <130/80 mmHg 1

Critical Implementation Points

Monotherapy considerations:

• Consider monotherapy only in low-risk grade 1 hypertension and in patients >80 years or frail 1
• Most patients require at least two drugs to achieve BP goals 7

Single-pill combinations:

• Use when possible to improve adherence 1, 2
• Simplify regimens with long-acting drugs 2

Monitoring:

• Check medication adherence regularly 1, 2
• If BP remains uncontrolled despite optimal therapy, refer to a specialist with hypertension expertise 1

Common Pitfalls and Caveats

Avoid combining two RAS blockers (ACE inhibitor and ARB) due to increased risk of adverse effects without additional benefit 1, 2

Exercise caution when combining beta-blockers with thiazide diuretics in patients at high risk of developing diabetes (strong family history of type 2 diabetes, obesity, impaired glucose tolerance, metabolic syndrome, South Asian or African-Caribbean descent) 7

Avoid overaggressive diastolic BP reduction in patients with established ischemic heart disease, as this may increase coronary events 2

Patient education improves treatment persistence and is essential for long-term BP control 2

Cardiovascular Risk Reduction Beyond BP Control

For patients with 10-year cardiovascular disease risk ≥20%:

• Consider aspirin 75 mg daily if age ≥50 years and BP controlled to <150/90 mmHg 7
• Consider statin therapy if total cholesterol ≥3.5 mmol/L 7

For secondary prevention (including type 2 diabetes):

• Aspirin for all patients unless contraindicated 7
• Statin therapy if total cholesterol ≥3.5 mmol/L 7