What are the updated guidelines for managing hypertension?

Updated Hypertension Management Guidelines

Definition and Blood Pressure Classification

Hypertension is defined as persistent blood pressure ≥140/90 mmHg according to European guidelines, though American guidelines use a lower threshold of ≥130/80 mmHg. 1, 2

The most recent classification system includes:

• Optimal: <120/<80 mmHg 3
• Normal: 120-129/80-84 mmHg 3
• High normal: 130-139/85-89 mmHg 3
• Grade 1 hypertension: 140-159/90-99 mmHg 3
• Grade 2 hypertension: 160-179/100-109 mmHg 3
• Grade 3 hypertension: ≥180/≥110 mmHg 3

Blood Pressure Measurement Technique

Accurate diagnosis requires multiple office measurements confirmed by out-of-office monitoring. 1, 2

Key measurement requirements:

• Measure blood pressure in both arms at first visit; use the arm with higher readings for subsequent measurements 2
• Use validated automated upper arm cuff devices with appropriate cuff size 2
• Take two or more readings at each visit before making treatment decisions 1
• Confirm diagnosis with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 2
• Measure standing blood pressure in elderly patients and those with diabetes to detect orthostatic hypotension 1

Lifestyle Modifications (First-Line for All Patients)

All patients with elevated BP or hypertension must implement lifestyle modifications before or alongside pharmacological treatment. 1, 2

Specific interventions with proven efficacy:

• Weight reduction to ideal body weight (reduces BP in both normotensive and hypertensive individuals) 1, 4
• Dietary sodium restriction (eliminate table salt; particularly effective in hypertensive patients) 1, 4
• Increased potassium intake through diet 2, 4
• DASH or Mediterranean diet high in fruits, vegetables, and low-fat dairy products 1, 2
• Regular aerobic exercise: 150 minutes/week of moderate activity, complemented with resistance training 2-3 times/week 1, 2
• Alcohol limitation: <21 units/week for men, <14 units/week for women 1, 2
• Smoking cessation 1

The BP-lowering effects of these interventions are partially additive and enhance pharmacological therapy efficacy. 4

Pharmacological Treatment Initiation

Start pharmacological treatment promptly alongside lifestyle modifications for confirmed BP ≥140/90 mmHg (European guidelines) or ≥130/80 mmHg with high cardiovascular risk (American guidelines). 1, 2

First-Line Medication Classes

The three first-line drug classes are thiazide/thiazide-like diuretics, ACE inhibitors or ARBs, and calcium channel blockers. 1, 2, 4

Specific agents include:

• Thiazide-like diuretics: chlorthalidone or hydrochlorothiazide 4
• ACE inhibitors: lisinopril 5, enalapril 4
• ARBs: candesartan 4
• Calcium channel blockers: amlodipine 6, 4

Race-Based Treatment Algorithm

For non-Black patients: Start with low-dose ACE inhibitor or ARB, with option to add CCB or thiazide-like diuretic as second agent 2

For Black patients: Start with low-dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 2

Combination Therapy Strategy

Most patients require at least two drugs to achieve BP goals; initiate upfront combination therapy with single-pill combinations for most adults with confirmed hypertension. 2, 4

Single-pill combinations improve adherence and should be used whenever possible. 2 Simplifying drug regimens with long-acting medications and combination pills enhances treatment persistence. 1

Blood Pressure Targets

Target systolic BP of 120-129 mmHg for most adults if well tolerated, with a general target of <130/80 mmHg. 1, 2

Age-specific targets:

• Adults <65 years: <130/80 mmHg 1, 2
• Adults ≥65 years: SBP <130 mmHg with individualized targets based on frailty 2
• Adults ≥85 years: More lenient targets may be considered if frail or symptomatic orthostatic hypotension present 1

Special Population Targets

Diabetes: <130/80 mmHg using RAS inhibitor plus CCB and/or thiazide-like diuretic 2

Chronic kidney disease: <130/80 mmHg with RAS inhibitors as first-line therapy 2

Cardiovascular Risk Assessment

Treatment intensity should be guided by total cardiovascular risk, not BP values alone. 3

High-risk patients include those with:

• Established cardiovascular disease 3
• Diabetes 3
• Severely elevated single risk factors 3

For patients with 10-year CVD risk ≥20%, consider aspirin 75 mg daily if age ≥50 years and BP controlled to <150/90 mmHg, plus statin therapy if total cholesterol ≥3.5 mmol/L. 2

Treatment Adherence and Monitoring

Medications should be taken at the most convenient time of day to establish habitual patterns and improve adherence. 1

Key adherence strategies:

• Provide clear written and oral instructions 3
• Simplify treatment regimens by reducing daily medication burden 3, 2
• Involve patient's family in treatment plans 3
• Utilize home BP monitoring 3
• Address side effects promptly and adjust medications as needed 3
• Check medication adherence regularly 2

Critical Pitfalls to Avoid

Never combine ACE inhibitors with ARBs due to increased adverse effects without additional benefit. 1

Beta-blockers are not first-line therapy for general hypertension unless specific indications exist (e.g., coronary artery disease, heart failure). 1

Improper BP measurement technique leads to inaccurate readings and inappropriate treatment decisions. 1

Failure to measure standing BP in elderly and diabetic patients misses orthostatic hypotension. 1

Gaining BP control as soon as possible improves long-term treatment persistence. 1

Resistant Hypertension

Resistant hypertension is defined as BP remaining above goal despite three optimally dosed antihypertensive medications including a diuretic. 1

Patients with uncontrolled BP despite optimal therapy should be referred to a specialist with hypertension expertise. 2

Lifelong Treatment

Treatment should be maintained lifelong, even beyond age 85 if well tolerated. 1 More gradual BP lowering may be appropriate in frail elderly patients. 1

Evidence for Benefit

A 10 mm Hg SBP reduction decreases CVD events by approximately 20-30%, with the largest benefit being stroke risk reduction. 4 Randomized trials have established that BP reduction itself, rather than specific drug properties, is largely responsible for cardiovascular benefits. 6, 5, 4