What are the current guidelines for managing hypertension?

Current Hypertension Management Guidelines

For confirmed hypertension (≥140/90 mmHg), initiate both lifestyle modifications and pharmacological therapy simultaneously—do not delay drug treatment while attempting lifestyle changes alone. 1

Blood Pressure Diagnosis and Confirmation

• Confirm hypertension using out-of-office measurements: home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg validates office readings of ≥140/90 mmHg. 1, 2
• Use validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms at first visit and using the arm with higher readings for subsequent measurements. 2
• Record two or more blood pressures at each visit, assessing thresholds on several occasions before confirming diagnosis. 1
• Measure standing pressures in elderly patients and those with diabetes to detect orthostatic hypotension. 1

Blood Pressure Classification

• Non-elevated BP: <120/70 mmHg 1
• Elevated BP: 120-139/70-89 mmHg 1, 2
• Grade 1 Hypertension: 140-159/90-99 mmHg 2
• Grade 2 Hypertension: ≥160/100 mmHg 2

Treatment Initiation Strategy

For confirmed hypertension (≥140/90 mmHg): Start pharmacological therapy immediately alongside lifestyle interventions, regardless of cardiovascular disease (CVD) risk. 1 This represents a major shift from older guidelines that recommended lifestyle-only trials for mild hypertension. 1

For elevated BP (120-139/70-89 mmHg): Treatment depends on risk stratification:

• High-risk patients (established CVD, diabetes, chronic kidney disease, familial hypercholesterolemia, or hypertension-mediated organ damage): Start pharmacological therapy immediately. 1
• 10-year CVD risk ≥10%: Start pharmacological therapy. 1
• 10-year CVD risk 5-<10% with risk modifiers: Start pharmacological therapy. 1
• 10-year CVD risk <10% without high-risk conditions: Lifestyle modifications only. 1

Lifestyle Modifications (All Patients)

These interventions provide additive BP reductions of 10-20 mmHg and should be emphasized even when starting medications: 2

• Sodium restriction: Limit intake to <2g/day (equivalent to <5g salt/day or <100 mmol/day). 2, 3, 4
• Weight management: Achieve BMI 18.5-24.9 kg/m² and waist circumference <102 cm (men) or <88 cm (women). 2, 5
• Physical activity: 150 minutes/week of moderate aerobic exercise (or 30-60 minutes on 4-7 days/week). 2, 4
• Alcohol limitation: ≤14 units/week for men, ≤9 units/week for women, with alcohol-free days each week. 1, 2
• Dietary pattern: Adopt DASH or Mediterranean diet emphasizing fruits, vegetables, low-fat dairy, whole grains, and reduced saturated fat. 2, 3
• Smoking cessation: Mandatory recommendation for all patients. 1, 2

Pharmacological Treatment Algorithm

Initial Therapy for Confirmed Hypertension (≥140/90 mmHg)

Start with two-drug combination therapy as initial treatment (preferably as a single-pill combination): 1, 2

For non-Black patients:

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker (CCB), OR
• RAS blocker + thiazide/thiazide-like diuretic 1, 2

For Black patients:

• Dihydropyridine CCB + thiazide/thiazide-like diuretic (more effective than RAS blocker combinations) 2, 6

Exceptions to combination therapy (consider monotherapy):

• Age ≥85 years
• Symptomatic orthostatic hypotension
• Moderate-to-severe frailty
• Elevated BP (120-139/70-89 mmHg) with specific indication for treatment 1

Step-Up Therapy for Uncontrolled BP

If BP not controlled on two-drug combination:

• Add third agent: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic (preferably single-pill combination). 1, 2

If BP not controlled on three-drug combination:

• Add spironolactone 25-50mg daily as the preferred fourth-line agent. 1, 2

If spironolactone ineffective or not tolerated:

• Consider eplerenone, beta-blocker (if not already indicated), centrally acting agent, alpha-blocker, hydralazine, or potassium-sparing diuretic. 1

Critical pitfall: Never combine two RAS blockers (ACE inhibitor + ARB)—this increases adverse events without additional benefit. 1, 2

Blood Pressure Targets

Standard target for most patients: <130/80 mmHg 2, 4

European guidelines recommend: Systolic BP 120-129 mmHg if well tolerated 1, 2

Minimum acceptable target: <140/90 mmHg 1, 2

Elderly patients: Individualize targets based on frailty, but do not automatically accept higher targets. 2

Diabetes or chronic kidney disease: <130/80 mmHg 2, 5

Timeline: Achieve target BP within 3 months of initiating or modifying therapy. 1, 2

Specific Drug Considerations

First-Line Agents

Thiazide/thiazide-like diuretics: Hydrochlorothiazide 12.5-50mg daily or chlorthalidone 12.5-25mg daily (chlorthalidone preferred for longer duration of action). 2, 4

ACE inhibitors: Lisinopril, enalapril (less effective as monotherapy in Black patients). 7, 4, 5

ARBs: Losartan, candesartan, olmesartan, valsartan. 2, 4

Dihydropyridine CCBs: Amlodipine 5-10mg daily. 2, 6, 4

Beta-blockers: Reserve for specific indications (coronary artery disease, heart failure, post-MI, heart rate control) rather than routine first-line use, especially in patients ≥60 years. 1, 2, 5

Compelling Indications for Specific Agents

Post-MI or angina: Beta-blockers + ACE inhibitors 5, 8

Heart failure: ACE inhibitors + beta-blockers 5, 8

Cerebrovascular disease: ACE inhibitor + diuretic combination 5, 8

Chronic kidney disease (non-diabetic with proteinuria): ACE inhibitors 5, 8

Diabetes mellitus: ACE inhibitors or ARBs (or thiazides/dihydropyridine CCBs if no albuminuria) 5, 8

Monitoring and Follow-Up

• Frequency: See patients every 1-3 months until BP controlled. 1
• After medication changes: Reassess within 2-4 weeks. 2
• Laboratory monitoring: Check serum potassium and creatinine 2-4 weeks after initiating RAS blockers or diuretics. 2
• Medication adherence: Verify adherence before escalating therapy—non-adherence is the most common cause of apparent treatment resistance. 2

Resistant Hypertension

Definition: BP ≥140/90 mmHg despite optimal doses of three-drug therapy (including a diuretic). 2

Management approach:

1. Confirm true hypertension with home or ambulatory BP monitoring
2. Verify medication adherence
3. Screen for secondary causes (renal artery stenosis, primary aldosteronism, obstructive sleep apnea, pheochromocytoma)
4. Add spironolactone 25-50mg daily
5. If still uncontrolled, refer to hypertension specialist 2

Critical Pitfalls to Avoid

• Do not delay pharmacological therapy in confirmed hypertension (≥140/90 mmHg) while attempting lifestyle modifications alone—this increases cardiovascular risk. 1
• Do not use monotherapy as initial treatment for most patients with confirmed hypertension—combination therapy is more effective and achieves targets faster. 1
• Do not add a fourth drug class before optimizing doses of the current three-drug regimen. 2
• Do not combine ACE inhibitor with ARB—this increases adverse events without benefit. 1, 2
• Do not use beta-blockers as routine first-line therapy unless compelling indications exist. 1, 2
• Do not accept suboptimal BP control in elderly patients without attempting guideline-directed therapy—age alone is not a contraindication to achieving targets. 1

Single-Pill Combinations

Strongly recommended when using combination therapy to improve adherence and simplify regimens. 1, 2 Fixed-dose combinations are now the preferred approach over separate pills for the same medications.