What are the guidelines for managing hypertension?

Hypertension Management Guidelines

For most patients with hypertension, initiate drug treatment at sustained BP ≥160/100 mmHg or at 140-159/90-99 mmHg if target organ damage, established cardiovascular disease, diabetes, or 10-year CVD risk ≥20% is present, targeting BP <140/85 mmHg for most patients and <130/80 mmHg for those with diabetes, renal impairment, or established cardiovascular disease. 1, 2, 3

Diagnosis and Blood Pressure Measurement

• Measure BP 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, 3
• 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 1, 2, 3
• 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 must include:

• Urine testing for blood and protein 1, 2
• Blood electrolytes and creatinine 1, 2
• Blood glucose 1, 2
• Serum cholesterol 1, 2
• 12-lead ECG 1, 2
• Formal estimation of 10-year cardiovascular disease risk 1, 2

Treatment Thresholds

Urgent treatment is required for:

• Accelerated hypertension (severe hypertension with grade III-IV retinopathy) 4
• Particularly severe hypertension (>220/120 mmHg) 4
• Impending complications such as transient ischemic attack or left ventricular failure 4

Standard treatment thresholds:

• Start drug treatment in all patients with sustained SBP ≥160 mmHg or DBP ≥100 mmHg despite non-pharmacological measures 4, 1, 2
• For sustained SBP 140-159 mmHg or DBP 90-99 mmHg, initiate treatment if target organ damage, established cardiovascular disease, diabetes, or 10-year CVD risk ≥20% is present 4, 1, 2

Blood Pressure Targets

For most non-diabetic patients, target BP is ≤140/85 mmHg (with a minimum acceptable audit standard of <150/90 mmHg) 4, 1, 2

For patients with diabetes, chronic kidney disease, or established cardiovascular disease, target BP is ≤130/80 mmHg 4, 1, 2, 3

• When using ambulatory BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents 4, 1
• The evidence supports a "lower the better" policy for optimal blood pressure in higher-risk populations 4

Lifestyle Modifications

All patients with hypertension, borderline, or high-normal blood pressure must receive lifestyle modification recommendations, which can lower systolic BP by approximately 5 mmHg per intervention 1, 2, 5

For patients with grade 1 (mild) hypertension and no complications, evaluate lifestyle measures for up to six months before initiating drug therapy 4

Specific interventions include:

• Weight reduction: Achieve ideal body weight; approximately 1 mmHg SBP reduction per 1 kg weight loss 2
• DASH diet: Emphasize fruits, vegetables, whole grains, low-fat dairy products with reduced saturated and total fat; reduces SBP by ~5 mmHg 2
• Sodium restriction: Optimal goal <1500 mg/day; reduces SBP by 1-3 mmHg per 1000 mg decrease in sodium intake 2
• Physical activity: Aerobic exercise 5-7 times/week for 30-60 minutes/session; reduces SBP by ~5 mmHg 2
• Alcohol moderation: Men ≤2 standard drinks/day, women ≤1 standard drink/day; reduces SBP by ~4 mmHg 2
• Potassium supplementation: Optimal goal 3500-5000 mg/day; reduces SBP by ~5 mmHg 2

Continue lifestyle measures even when antihypertensive therapy is initiated, as they complement BP-lowering effects of drugs and may reduce the dose or number of drugs required 4, 1

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

Initial drug selection should include:

• Thiazide or thiazide-like diuretics (chlorthalidone preferred) 1, 2, 5
• Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) 1, 2, 5
• Calcium channel blockers (amlodipine as first-line) 1, 2, 5
• Beta-blockers (in patients younger than 60 years) 1

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, 3

Specific Drug Considerations

• Lisinopril (ACE inhibitor) is indicated for hypertension treatment to lower blood pressure and reduce cardiovascular events; may be administered alone or with other antihypertensive agents 6
• Amlodipine (calcium channel blocker) is indicated for hypertension treatment and may be used alone or in combination with other antihypertensive agents 7
• Chlorthalidone is the preferred thiazide-like diuretic based on clinical trial data 2

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
• 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

Special Considerations for Secondary Hypertension

Suspect secondary hypertension and refer for specialist evaluation when:

• Hypokalemia with increased or high normal plasma sodium (suggesting Conn's syndrome) 4
• Elevated serum creatinine 4, 1
• Proteinuria or hematuria 4, 1
• Sudden onset or worsening of hypertension 4, 1
• Resistant to multidrug regimen (≥3 drugs) 4, 1
• Young age (any hypertension <20 years; needing treatment <30 years) 4, 1

Monitoring and Follow-up

• Regular BP monitoring using both office and home readings is necessary for optimal management 1, 2, 3
• Annual reassessment of cardiovascular risk is recommended 1, 2, 3
• Monitor for adverse effects of medications and adjust therapy as needed 1, 2, 3
• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence 2, 3

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 4, 1, 2
• Not considering secondary causes in resistant hypertension or young patients 1