What are the guidelines for managing hypertension?

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, 2

• Ambulatory blood pressure monitoring (ABPM) is indicated for unusual BP variability, suspected white coat hypertension, or resistant hypertension, with expected values approximately 10/5 mmHg lower than office readings. 3, 1, 2
• Home blood pressure monitoring is the most practical method to document BP for medication titration and is more sensitive than office readings for detecting masked hypertension. 2
• Routine investigations should 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 treatment decisions. 1, 2

Treatment Thresholds

Drug treatment should be initiated in all patients with sustained systolic BP ≥160 mmHg or sustained diastolic BP ≥100 mmHg despite non-pharmacological measures. 3, 2

• For sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg, initiate treatment if any of the following are present: target organ damage, established cardiovascular disease, diabetes mellitus, or 10-year cardiovascular disease risk ≥20%. 3, 2
• Urgent treatment is needed for accelerated hypertension (severe hypertension with grade III-IV retinopathy), particularly severe hypertension (>220/120 mmHg), or impending complications such as transient ischemic attack or left ventricular failure. 3

Blood Pressure Targets

For most patients, the target blood pressure is ≤140/85 mmHg. 3, 1, 2

• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, the target blood pressure is ≤130/80 mmHg. 3, 1, 2, 4
• When using ambulatory BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents. 3, 1
• The minimum acceptable audit standard for most patients is <150/90 mmHg. 3, 2

Lifestyle Modifications

All patients with hypertension, borderline, or high-normal blood pressure should receive lifestyle modification recommendations, which can lower systolic BP by approximately 5 mmHg per intervention. 3, 2

Specific Lifestyle Interventions:

• Sodium restriction to 5-6 g per day (optimal goal <1500 mg/day), which can reduce SBP by 1-3 mmHg per 1000 mg decrease in sodium intake. 3, 2
• Weight reduction to BMI of 25 kg/m² and waist circumference <102 cm in men and <88 cm in women, which can reduce SBP by approximately 1 mmHg for every 1 kg weight loss. 3, 2
• Regular aerobic exercise for at least 30 minutes of moderate-intensity dynamic exercise on 5-7 days per week (walking, jogging, cycling, or swimming), which can reduce SBP by ~5 mmHg. 3, 2
• Alcohol moderation to no more than 20-30 g of ethanol per day in men and 10-20 g per day in women (men ≤2 standard drinks/day, women ≤1 standard drink/day), which can reduce SBP by ~4 mmHg. 3, 2
• Increased consumption of vegetables, fruits, and low-fat dairy products (DASH diet), which can reduce SBP by ~5 mmHg. 3, 2
• Potassium supplementation with an optimal goal of 3500-5000 mg/day, which can reduce SBP by ~5 mmHg. 2
• Smoking cessation advice should be given to all smokers with assistance offered. 3

Dynamic resistance training on 2-3 days per week can also be advised, as it reduces BP and improves metabolic parameters; however, isometric exercises are not recommended due to limited data. 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. 2

First-Line Agents:

• Thiazide or thiazide-like diuretics (including thiazides, chlorthalidone, and indapamide), angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and beta-blockers are all suitable for initiation and maintenance of antihypertensive treatment. 3, 5, 6
• Chlorthalidone is the preferred thiazide-like diuretic. 2
• Amlodipine is the first-line calcium channel blocker. 2, 5

Combination Therapy:

• 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. 2, 4
• The main benefits of antihypertensive treatment are due to lowering of BP per se and are largely independent of the drugs employed. 3
• Beta-blockers are equally as effective as other major classes in preventing coronary outcomes and highly effective in preventing CV events, despite some meta-analyses suggesting they may be inferior to calcium antagonists for stroke. 3

Medication Timing:

• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence. 2, 4

Special Populations and Considerations

When to Suspect Secondary Hypertension:

• Elevated serum creatinine or proteinuria/hematuria. 3, 1
• Hypokalaemia with increased or high normal plasma sodium (suggesting Conn's syndrome). 3
• Sudden onset or worsening of hypertension. 3, 1
• Resistance to multidrug regimen (≥3 drugs). 3, 1
• Young age (any hypertension <20 years; needing treatment <30 years). 3, 1

High-Risk Patients:

• Patients with diabetes, hyperlipidemia, or other cardiovascular risk factors would be expected to benefit from more aggressive treatment to lower blood pressure goals. 5, 6
• An SBP reduction of 10 mmHg decreases risk of CVD events by approximately 20-30%. 7

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%. 2
• 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. 2
• 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. 2

Monitoring and Follow-up

• Regular BP monitoring using both office and home readings is necessary for optimal management. 1, 2, 4
• Annual reassessment of cardiovascular risk is recommended. 1, 2, 4
• Monitor for adverse effects of medications and adjust therapy as needed. 1, 2, 4

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis. 1
• Not considering white coat hypertension when office readings are elevated. 1
• Inadequate dosing or inappropriate combinations of antihypertensive medications. 1
• Not addressing lifestyle modifications alongside pharmacological treatment. 1
• Overlooking the need for lower BP targets (<130/80 mmHg) in high-risk patients with diabetes, chronic kidney disease, or established cardiovascular disease. 3, 1, 2
• Not considering secondary causes in resistant hypertension or young patients. 3, 1