What are the diagnostic criteria and initial treatment for hypertension?

Diagnosis of Hypertension

Hypertension is diagnosed when blood pressure measurements average ≥140/90 mmHg on multiple occasions, confirmed through out-of-office monitoring (ambulatory or home blood pressure monitoring) before initiating treatment, particularly for readings between 140-159/90-99 mmHg. 1, 2

Diagnostic Criteria and Measurement Technique

Blood Pressure Measurement Standards

• Use a properly maintained, calibrated, and validated device with appropriate cuff size for arm circumference 1
• Measure seated blood pressure with arm supported at heart level, patient relaxed, avoiding talking during measurement 1
• Record the mean of at least 2 readings per visit; more recordings needed if marked differences exist 1
• Never treat based on an isolated reading 1
• Standing blood pressure should be measured in elderly or diabetic patients to exclude orthostatic hypotension 1

Confirmation Strategy

• For blood pressure 140-159/90-99 mmHg: Confirm diagnosis using ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) before starting treatment 2
• ABPM defines hypertension as daytime average ≥135/85 mmHg 1
• Diagnosis requires measurements on at least 2-3 separate visits with 2 measurements per visit 2
• Blood pressure should be measured at least every 5 years until age 80 in normotensive individuals 1
• Annual monitoring for those with "high-normal" values (130-139/85-89 mmHg) 1

Initial Evaluation

• Calculate 10-year cardiovascular risk using ASCVD calculator (US) or SCORE (Europe) 2
• Routine laboratory investigations: urinalysis for protein and blood, serum creatinine and electrolytes, fasting blood glucose, lipid profile (total and HDL cholesterol), and electrocardiogram 1, 2
• Assess for secondary causes, target organ damage, and cardiovascular risk factors 1

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Initial Treatment of Hypertension

For stage 1 hypertension (140-159/90-99 mmHg) with 10-year cardiovascular risk <10% and no target organ damage or diabetes, initiate lifestyle modifications alone; for higher risk patients or stage 2 hypertension (≥160/100 mmHg), start both lifestyle modifications and pharmacological therapy simultaneously. 2

Treatment Decision Algorithm

Stage 1 Hypertension (140-159/90-99 mmHg)

• Low risk (10-year CVD risk <10%, no target organ damage, no diabetes): Lifestyle modifications alone 2
• High risk (10-year CVD risk ≥10% OR target organ damage OR diabetes): Lifestyle modifications PLUS pharmacological therapy 2

Stage 2 Hypertension (≥160/100 mmHg)

• Immediate combination of lifestyle modifications and pharmacological therapy 2

Non-Pharmacological Interventions

All hypertensive patients require lifestyle modifications regardless of medication status: 2, 3

• Sodium restriction to <1500 mg/day 2
• Increased potassium intake (3500-5000 mg/day) 2
• Weight loss if overweight or obese 2, 3
• Regular physical activity: 90-150 minutes per week 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 2
• Healthy dietary pattern (DASH diet approach) 3

Pharmacological Treatment

First-Line Agents

The following four drug classes are recommended as first-line therapy: 2, 3

• Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide 12.5-25 mg, chlorthalidone) 2, 3
• ACE inhibitors (e.g., lisinopril 10 mg initial dose) 2, 4
• Angiotensin receptor blockers (ARBs) 2, 3
• Calcium channel blockers (e.g., amlodipine) 2, 3

Specific Dosing for Lisinopril

• Initial dose: 10 mg once daily in adults 4
• Usual dosage range: 20-40 mg per day as single daily dose 4
• If taking diuretics: Start with 5 mg once daily 4
• Doses up to 80 mg have been used but provide no greater effect 4

Special Population Considerations

• Diabetes or chronic kidney disease: Prefer ACE inhibitors or ARBs as initial agents 2
• Black patients: Initiate with calcium channel blocker or thiazide diuretic 1
• History of myocardial infarction, heart failure, or angina: β-blockers indicated 1

Critical Contraindication

• Never combine ACE inhibitors with ARBs 2

Blood Pressure Targets

Target blood pressure varies by patient characteristics: 2, 3

• Adults <65 years: <130/80 mmHg 3
• Adults ≥65 years: SBP <130 mmHg 3
• Patients with diabetes, chronic kidney disease, or established CVD: <130/80 mmHg 2
• Minimum acceptable control (audit standard): <150/90 mmHg 1

Monitoring and Follow-Up

Laboratory Monitoring

• Monitor electrolytes and renal function 2-4 weeks after initiating ACE inhibitors, ARBs, or diuretics, then regularly thereafter 2

Blood Pressure Monitoring

• Regular blood pressure monitoring with treatment adjustment as needed to achieve target 2
• Consider ABPM for unusual variability, suspected white coat hypertension, resistant hypertension, or nocturnal hypertension 1

Common Pitfalls to Avoid

• Do not use immediate-release nifedipine for hypertensive urgencies 5
• Avoid β-blockers as first-line therapy in general population without specific indications 1
• The appearance of hypotension after initial dosing does not preclude careful subsequent titration 4
• If adding a diuretic to lisinopril, the lisinopril dose may need reduction 4