What are the guidelines for managing hypertension?

Hypertension Management Guidelines

For most patients with hypertension, target blood pressure should be <140/85 mmHg, but patients with diabetes, chronic kidney disease, or established cardiovascular disease require a lower target of <130/80 mmHg. 1, 2, 3

Diagnosis and Blood Pressure Measurement

Proper BP measurement technique is critical to avoid misdiagnosis:

• Measure BP with a validated device, patient seated with arm at heart level, taking at least two measurements at each of several visits before confirming diagnosis 4, 1, 2
• Deflate the cuff at 2 mm/s and record BP to the nearest 2 mmHg, with diastolic pressure recorded as disappearance of sounds (phase V) 4
• Ambulatory BP monitoring (ABPM) is indicated when: clinic BP shows unusual variability, hypertension is resistant to three or more drugs, symptoms suggest hypotension, or to diagnose white coat hypertension 4, 1, 2
• ABPM and home BP readings are expected to be approximately 10/5 mmHg lower than office readings 4, 2, 3

Initial workup should include:

• Urine strip test for blood and protein 4, 1
• Blood electrolytes and creatinine 4, 1
• Blood glucose 4, 1
• Serum total:HDL cholesterol ratio 4, 1
• 12-lead electrocardiograph 4, 1
• Formal estimation of 10-year cardiovascular disease risk 1, 2

Treatment Thresholds

Urgent treatment is needed for:

• Accelerated hypertension (severe hypertension with grade III-IV retinopathy) 4
• Particularly severe hypertension (>220/120 mmHg) 4
• Impending complications such as transient ischemic attack or left ventricular failure 4

Standard treatment thresholds:

• Start drug treatment in all patients with sustained SBP ≥160 mmHg or DBP ≥100 mmHg despite non-pharmacological measures 4, 1, 2
• For sustained SBP 140-159 mmHg or DBP 90-99 mmHg, initiate treatment if target organ damage is present, established cardiovascular disease exists, diabetes is present, or 10-year CVD risk is ≥20% 4, 1, 2

Treatment Targets

The evidence supports a "lower is better" approach for high-risk patients:

• For most non-diabetic patients without complications, target BP is <140/85 mmHg (minimum audit standard <150/90 mmHg) 4, 1, 2
• For patients with diabetes, renal impairment, or established cardiovascular disease, target BP is <130/80 mmHg 4, 1, 2, 3
• The HOT trial demonstrated optimal BP for reduction of major cardiovascular events was 139/83 mmHg, with no harm from lowering below this level 4

Lifestyle Modifications

All patients with hypertension or high-normal BP should receive lifestyle modification recommendations, which can lower systolic BP by approximately 5 mmHg per intervention: 2

• Weight reduction: Achieve ideal body weight (BMI 18.5-24.9 kg/m²) and waist circumference <102 cm for men, <88 cm for women; approximately 1 mmHg SBP reduction per 1 kg weight loss 4, 2, 5
• Physical activity: 30-60 minutes of aerobic exercise (predominantly dynamic like brisk walking, not isometric like weight training) 4-7 days per week; can reduce SBP by ~5 mmHg 4, 2, 5
• Sodium restriction: Limit intake to 65-100 mmol/day in hypertensive patients and <100 mmol/day in normotensive at-risk individuals; optimal goal <1500 mg/day can reduce SBP by 1-3 mmHg per 1000 mg decrease 4, 2, 5
• DASH diet: Emphasize fruits, vegetables, whole grains, low-fat dairy products with reduced saturated and total fat; can reduce SBP by ~5 mmHg 2, 6
• Alcohol moderation: Limit to ≤2 standard drinks/day for men and ≤1 standard drink/day for women (≤14 units/week for men, ≤9 units/week for women); can reduce SBP by ~4 mmHg 4, 2, 5
• Potassium supplementation: Optimal goal 3500-5000 mg/day; can reduce SBP by ~5 mmHg 2
• Smoking cessation: Essential for overall cardiovascular risk reduction 4, 3

For patients with grade 1 (mild) hypertension and no complications, evaluate lifestyle measures for up to six months before initiating drug therapy. 4

Pharmacological Management

Most patients will require at least two antihypertensive drugs to achieve recommended BP goals: 2, 3

First-line agents include:

• Thiazide or thiazide-like diuretics (chlorthalidone preferred) 2, 6, 7
• ACE inhibitors or ARBs 2, 6
• Long-acting calcium channel blockers (amlodipine as first-line CCB) 2, 6
• Beta-blockers (in patients <60 years of age) 4, 8

Preferred initial therapy:

• Fixed-dose combinations are recommended when no cost disadvantages exist, preferably combining a renin-angiotensin system (RAS) blocker with either a dihydropyridine CCB or thiazide-like diuretic 2, 3
• For isolated systolic hypertension, long-acting dihydropyridine CCBs or ARBs are first-line 4, 8

Compelling indications for specific agents:

• Angina, recent MI, or heart failure: Beta-blockers and ACE inhibitors 8, 9
• Cerebrovascular disease: ACE inhibitor plus diuretic combination 8, 9
• Nondiabetic chronic kidney disease with proteinuria: ACE inhibitors 8, 9
• Diabetes mellitus: ACE inhibitors or ARBs (or thiazides/dihydropyridine CCBs in patients without albuminuria) 8, 9

Adjunctive Cardiovascular Risk Reduction

Once BP is controlled:

• Consider aspirin therapy 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% 2, 8
• Initiate statin therapy in patients up to at least 80 years with 10-year CVD risk ≥20% and total cholesterol ≥3.5 mmol/L 2, 8
• 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 2

Indications for Specialist Referral

Refer when:

• Urgent treatment indicated: malignant hypertension or impending complications 4
• Suspected secondary hypertension: hypokalaemia with increased/high-normal plasma sodium (Conn's syndrome), elevated serum creatinine, proteinuria or hematuria, sudden onset or worsening of hypertension, young age (any hypertension <20 years; needing treatment <30 years) 4, 1
• Resistant to multidrug regimen (≥3 drugs) 4
• Special circumstances: unusual BP variability, possible white coat hypertension, pregnancy 4

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements at multiple visits before diagnosis 1, 2
• Not considering white coat hypertension when office readings are elevated (use ABPM or home BP monitoring) 1, 2
• Inadequate dosing or inappropriate combinations of antihypertensive medications 1
• Not addressing lifestyle modifications alongside pharmacological treatment 1, 2
• Overlooking the need for lower BP targets (<130/80 mmHg) in high-risk patients with diabetes, CKD, or established CVD 4, 1, 2
• Not considering secondary causes in resistant hypertension or young patients 4, 1
• Underestimating the importance of home BP monitoring, which is more sensitive than office readings for detecting masked hypertension 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 1, 2
• Monitor for adverse effects of medications and adjust therapy as needed 1, 3
• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence 2, 3
• An SBP reduction of 10 mmHg decreases risk of CVD events by approximately 20-30% 6