What are the guidelines for managing hypertension?

Hypertension Management Guidelines

Blood Pressure Measurement and Diagnosis

Blood pressure should be measured with the patient seated, arm at heart level, using a validated device, with at least two measurements taken at each of several visits before confirming the diagnosis. 1, 2

• The cuff bladder size must be adjusted for arm circumference, deflated at 2 mm/s, and BP measured to the nearest 2 mm Hg, with diastolic pressure recorded at disappearance of sounds (phase V). 3

• Ambulatory blood pressure 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. 3, 1 Expected ABPM values are approximately 10/5 mmHg lower than office readings. 3, 2

• Home blood pressure monitoring is the most practical method for medication titration and is more sensitive than office readings for detecting masked hypertension. 2

Initial Evaluation

All hypertensive patients require routine investigations including urine strip test for blood and protein, blood electrolytes and creatinine, blood glucose, serum total:HDL cholesterol ratio, and 12-lead ECG. 3, 1

• Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions. 1, 2

• Specialist referral is indicated for: malignant hypertension or impending complications requiring urgent treatment; suspected secondary causes (hypokalaemia with elevated sodium suggesting Conn's syndrome, elevated creatinine, proteinuria/hematuria, sudden onset or worsening hypertension, resistance to ≥3 drugs, age <30 years requiring treatment); or special situations like pregnancy. 3

Treatment Thresholds

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

For sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg, initiate drug treatment if target organ damage is present, established cardiovascular disease exists, diabetes is present, or 10-year cardiovascular disease risk is ≥20%. 3, 2

• Urgent treatment is needed for accelerated hypertension (severe hypertension with grade III-IV retinopathy), BP >220/120 mmHg, or impending complications such as transient ischemic attack or left ventricular failure. 3

Blood Pressure Targets

For most patients, the target BP is ≤140/85 mmHg (with a minimum acceptable audit standard of <150/90 mmHg). 3, 2

For patients with diabetes, chronic kidney disease, or established cardiovascular disease, the target BP is ≤130/80 mmHg. 3, 2, 4

• The HOT trial demonstrated that optimal BP for reduction of major cardiovascular events was 139/83 mmHg, with no harm from lowering BP below this level, though patients between 139/83 and 150/90 mmHg were not disadvantaged. 3

• When using ambulatory or home BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents. 3

Lifestyle Modifications

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

Specific Interventions:

• Weight reduction to achieve ideal body weight (BMI 18.5-24.9 kg/m²) can reduce systolic BP by approximately 1 mmHg for every 1 kg weight loss. 2 Waist circumference should be <102 cm in men and <88 cm in women. 2

• Sodium restriction with an optimal goal <1500 mg/day (65-100 mmol/day) can reduce systolic BP by 1-3 mmHg per 1000 mg decrease in sodium intake. 2

• The DASH diet emphasizing fruits, vegetables, whole grains, low-fat dairy products with reduced saturated and total fat can reduce systolic BP by ~5 mmHg. 2

• Aerobic exercise 5-7 times/week for 30-60 minutes/session (predominantly dynamic like brisk walking rather than isometric weight training) can reduce systolic BP by ~5 mmHg. 3, 2

• Alcohol moderation to ≤2 standard drinks/day for men and ≤1 standard drink/day for women (maximum 14 units/week for men, 9 units/week for women) can reduce systolic BP by ~4 mmHg. 3, 2

• Potassium supplementation with an optimal goal of 3500-5000 mg/day can reduce systolic BP by ~5 mmHg. 2

• Smoking cessation, increased intake of oily fish, and stress management in selected individuals should be recommended. 3, 2

• For patients requiring drug therapy, lifestyle measures should still be implemented as they complement BP-lowering effects of medications and may reduce the dose or number of drugs required. 3

Pharmacological Management

Most patients with hypertension will require at least two BP-lowering drugs to achieve recommended goals; fixed-dose combinations are preferred when no cost disadvantages exist. 2

Initial Drug Selection:

Fixed-dose combinations, preferably combining a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide-like diuretic, are recommended as initial therapy. 2

• First-line agents include thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, and calcium channel blockers. 1, 5

• Chlorthalidone is the preferred thiazide-like diuretic based on clinical trial data. 2, 5

• Amlodipine is recommended as the first-line calcium channel blocker. 2, 6

• Beta-blockers are appropriate for first-line therapy in patients <60 years of age or those with compelling indications such as angina, recent myocardial infarction, or heart failure. 1

Compelling Indications for Specific Agents:

• Patients with angina, recent myocardial infarction, or heart failure should receive beta-blockers and ACE inhibitors as first-line therapy. 7

• Patients with cerebrovascular disease should receive an ACE inhibitor plus diuretic combination. 7

• Patients with nondiabetic chronic kidney disease should receive ACE inhibitors. 7

• Patients with diabetes mellitus should receive ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs). 7

Adjunctive 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

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements at several visits before initiating treatment can lead to overdiagnosis. 1

• Not considering white coat hypertension when office readings are elevated—use ABPM or home monitoring to confirm. 1

• Inadequate dosing or inappropriate combinations of antihypertensive medications—most patients need at least two drugs, and fixed-dose combinations improve adherence. 2

• Not addressing lifestyle modifications alongside pharmacological treatment—these interventions are additive and can reduce medication requirements. 3, 2

• Overlooking the need for lower BP targets (<130/80 mmHg) in high-risk patients with diabetes, chronic kidney disease, or established cardiovascular disease. 3, 2

• Not considering secondary causes in resistant hypertension (≥3 drugs), young patients (<30 years), or those with sudden onset/worsening hypertension. 3, 1

Monitoring and Follow-up

Regular BP monitoring using both office and home readings is necessary for optimal management. 2, 4

• Annual reassessment of cardiovascular risk is recommended. 1, 2

• Monitor for adverse effects of medications and adjust therapy as needed. 1

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

• An SBP reduction of 10 mmHg decreases risk of cardiovascular events by approximately 20-30%, with the largest benefit being stroke risk reduction. 5