What are the treatment guidelines for hypertension?

Treatment Guidelines for Hypertension

Diagnosis and Confirmation

Hypertension is diagnosed when office BP is persistently ≥140/90 mmHg, confirmed by home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg. 1, 2

• Use validated automated upper arm cuff devices with appropriate cuff size for the patient 1, 2, 3
• Measure BP in both arms at first visit; use the arm with higher readings for subsequent measurements 1, 2, 3
• Take the average of 2 or more readings over 2-3 office visits to confirm diagnosis 1
• For BP <130/85 mmHg, remeasure after 3 years; for BP ≥130/85 mmHg, confirm with home or ambulatory monitoring 1, 2

Initial Risk Assessment

Before initiating treatment, assess for:

• Target organ damage (left ventricular hypertrophy, retinopathy, proteinuria, elevated creatinine) 1
• Cardiovascular disease, chronic kidney disease, or diabetes 1, 2
• 10-year cardiovascular risk using SCORE or ASCVD calculator 1
• Secondary causes of hypertension (particularly in young patients, sudden onset, or resistant hypertension) 1

Lifestyle Modifications

All patients with hypertension should implement lifestyle modifications immediately, which are complementary to—not replacements for—pharmacological therapy. 1, 3

• Dietary changes: DASH or Mediterranean diet rich in fruits, vegetables, low-fat dairy, with reduced saturated fat 1, 3
• Sodium restriction: Reduce intake to <5g salt (<2000mg sodium) per day 1
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly plus resistance training 2-3 times per week 3
• Weight loss: Maintain BMI 18.5-24.9 kg/m² if overweight or obese 1
• Alcohol moderation: Up to 2 drinks daily for men, 1 for women 1
• Smoking cessation 1, 3

Pharmacological Treatment Initiation

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

• Start drug treatment immediately in high-risk patients: those with CVD, CKD, diabetes, target organ damage, or aged 50-80 years 1, 2
• For low-moderate risk patients without these conditions, implement lifestyle modifications for 3-6 months; if BP remains elevated, initiate drug therapy 1, 2

Grade 2 Hypertension (≥160/100 mmHg)

• Start drug treatment immediately in all patients 1, 2

First-Line Medication Selection

The International Society of Hypertension recommends starting with combination therapy using single-pill combinations for better adherence and faster BP control. 1, 2, 3

For Non-Black Patients:

• Start with low-dose ACE inhibitor or ARB 1, 2, 4
• Add dihydropyridine calcium channel blocker (DHP-CCB) as second agent 1, 2, 3, 5
• Consider monotherapy only in low-risk Grade 1 hypertension or patients aged >80 years or frail 1

For Black Patients:

• Start with low-dose ARB plus DHP-CCB OR DHP-CCB plus thiazide/thiazide-like diuretic 1, 2, 3
• Black patients have smaller BP responses to ACE inhibitors/ARBs as monotherapy 4, 5

Medication Titration Algorithm

Step 1: Initial Therapy

• Non-Black: Low-dose ACE inhibitor/ARB 1, 2
• Black: Low-dose ARB + DHP-CCB or DHP-CCB + thiazide diuretic 1, 2

Step 2: Increase to Full Dose

• Titrate initial medication(s) to maximum tolerated dose before adding additional agents 1, 6

Step 3: Add Second Agent (if not already on combination)

• Add DHP-CCB for non-Black patients 1, 2, 3
• Add diuretic or ARB/ACE inhibitor for Black patients (whichever not already prescribed) 1

Step 4: Add Thiazide/Thiazide-Like Diuretic

• Add as third agent if not already included 1, 2, 3
• Chlorthalidone preferred over hydrochlorothiazide based on outcomes data 7, 8

Step 5: Resistant Hypertension Management

• Add spironolactone as the preferred fourth-line agent 1, 2, 6, 9
• Alternative fourth-line agents if spironolactone contraindicated or not tolerated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1, 2, 6
• Before adding fourth agent, exclude pseudoresistance: verify proper BP measurement technique, assess medication adherence, rule out white coat effect, and screen for secondary causes 1

Blood Pressure Targets

Target BP is <130/80 mmHg for most adults, including those with diabetes, CKD, or established CVD. 2, 3

• Initial goal: reduce BP by at least 20/10 mmHg 1, 2, 3
• For elderly patients, individualize target based on frailty status 1, 2
• Achieve target BP within 3 months of treatment initiation 1, 2, 3, 6

The British Hypertension Society recommends a minimum "audit standard" target of <150/90 mmHg for all treated patients, with optimal targets of <140/85 mmHg for most and <130/80 mmHg for high-risk patients 1

Monitoring and Follow-Up

• Schedule follow-up within 2-4 weeks initially to assess response and tolerability 3
• Check serum creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 3
• Monitor BP control regularly; home BP monitoring improves adherence and outcomes 1, 2
• Verify medication adherence at each visit, as this is a common cause of inadequate control 6

Special Population Considerations

Diabetes

• Preferred agents: ACE inhibitors or ARBs (especially with albuminuria); thiazides or DHP-CCBs acceptable without albuminuria 1, 2
• Target BP <130/80 mmHg 1, 2

Chronic Kidney Disease

• Preferred agents: ACE inhibitors or ARBs 2, 7
• Target BP <130/80 mmHg 1, 2

Coronary Artery Disease

• Consider RAS blockers, beta-blockers with or without CCBs 2

Heart Failure

• Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 2, 9

Previous Stroke

• Preferred agents: RAS blockers, CCBs, and diuretics 2

Inflammatory Rheumatic Diseases

• Preferentially use RAS inhibitors (evidence of overactive RAAS) and CCBs 1
• Avoid high doses of NSAIDs 1

Psychiatric Disorders/Depression

• Preferentially use RAS inhibitors and diuretics (fewer drug interactions with antidepressants) 1
• Use CCBs and alpha-1 blockers with caution due to orthostatic hypotension risk 1

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB)—this is potentially harmful 3
• Do not use immediate-release nifedipine for hypertensive urgencies 10
• Avoid clinical inertia: combination therapy is more effective than sequential monotherapy titration 3
• Do not discontinue lifestyle modifications once drug therapy starts—they enhance medication efficacy 1, 3
• Allow 2-4 weeks for full effect of dose adjustments before making further changes 6
• Do not add additional agents without first checking medication adherence 6

When to Refer to Specialist

• BP remains uncontrolled despite adherence to four-drug regimen including a diuretic 6
• Suspected secondary hypertension (young age, sudden onset, resistant to therapy, hypokalemia with elevated/high-normal sodium) 1
• Hypertensive emergency with acute end-organ damage requiring ICU admission 10