What are the management options for elevated blood pressure?

Management of Elevated Blood Pressure

For adults with elevated blood pressure (120-139/70-89 mmHg), begin with intensive lifestyle modifications for up to 3 months, then add pharmacological treatment only if cardiovascular disease (CVD) risk is ≥10% or high-risk conditions are present; for hypertension (≥140/90 mmHg), start combination pharmacological therapy immediately alongside lifestyle changes. 1

Blood Pressure Classification and Confirmation

• Non-elevated BP: <120/<70 mmHg 1
• Elevated BP: 120-139/70-89 mmHg 1
• Hypertension: ≥140/90 mmHg 1

All BP categories must be confirmed with out-of-office measurements using home blood pressure monitoring (HBPM) or 24-hour ambulatory blood pressure monitoring (ABPM) before initiating treatment. 1 For screening BP 120-139/70-89 mmHg, confirm with out-of-office measurements or repeated office visits. 1 For BP 140-159/90-99 mmHg, diagnosis should be based on ABPM/HBPM, or if not feasible, repeated office measurements. 1 When BP is ≥160/100 mmHg, confirm within 1 month, and if ≥180/110 mmHg, immediately exclude hypertensive emergency. 1

Risk Stratification for Treatment Decisions

High-Risk Conditions Warranting Immediate Treatment (Even with Elevated BP)

Patients with elevated BP (120-139/70-89 mmHg) require pharmacological treatment if they have any of these conditions: 1

• Moderate-to-severe chronic kidney disease (eGFR <60 mL/min/1.73 m² or urine albumin:creatinine ratio ≥30 mg/g) 1
• Established cardiovascular disease (coronary heart disease, cerebrovascular disease, peripheral arterial disease, heart failure) 1
• Hypertension-mediated organ damage (left ventricular hypertrophy, retinopathy, microalbuminuria) 1
• Diabetes mellitus 1
• Familial hypercholesterolemia 1

Risk Calculation for Others

For patients aged 40-69 years without the above conditions, use SCORE2 to calculate 10-year CVD risk. 1 For patients ≥70 years, use SCORE2-OP. 1 Treat with medications if predicted 10-year CVD risk is ≥10%. 1 For type 2 diabetes patients <60 years, consider SCORE2-Diabetes to identify those with <10% risk who may not need immediate medication. 1

Lifestyle Modifications (All Patients)

These interventions are mandatory for all patients with elevated BP or hypertension: 1

• Sodium restriction: Limit to approximately 2 g/day (equivalent to 5 g salt/day, roughly one teaspoon) 1
• Potassium supplementation: Increase intake by 0.5-1.0 g/day through potassium-enriched salt or fruits/vegetables 2
• Exercise: Moderate-intensity aerobic activity ≥150 min/week (30 min, 5-7 days/week) OR 75 min vigorous exercise/week, PLUS resistance training 2-3 times/week 1
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Diet: Adopt Mediterranean or DASH dietary pattern 1
• Alcohol: Limit to <100 g/week of pure alcohol (approximately 7-12 standard drinks depending on size); ideally avoid completely 1
• Sugar restriction: Maximum 10% of energy intake from free sugars; eliminate sugar-sweetened beverages 1
• Tobacco cessation: Mandatory with referral to cessation programs 1

Pharmacological Treatment

When to Start Medications

• Hypertension (≥140/90 mmHg): Start immediately with combination therapy 1
• Elevated BP (120-139/70-89 mmHg) with high CVD risk: Start after maximum 3 months of lifestyle intervention if BP remains elevated 1
• Diabetes with BP ≥130/80 mmHg: Start after maximum 3 months of lifestyle intervention 1

Initial Pharmacological Regimen

Start with combination therapy using a fixed-dose single-pill combination for most patients with confirmed hypertension. 1 This approach provides superior BP control compared to monotherapy and improves adherence. 1

Preferred initial combination: 1, 2

• RAS blocker (ACE inhibitor OR angiotensin receptor blocker)
• PLUS dihydropyridine calcium channel blocker (CCB)
• OR RAS blocker PLUS thiazide/thiazide-like diuretic

First-line drug classes with proven CVD event reduction: 1

• ACE inhibitors
• Angiotensin receptor blockers (ARBs)
• Dihydropyridine calcium channel blockers
• Thiazide and thiazide-like diuretics (chlorthalidone, indapamide)

Exceptions to Combination Therapy

Consider starting with monotherapy in: 1

• Patients aged ≥85 years
• Symptomatic orthostatic hypotension
• Moderate-to-severe frailty
• Elevated BP (not hypertension) with indication for treatment

Escalation Strategy

If BP not controlled with two-drug combination, add a third drug (typically the missing component from RAS blocker + CCB + diuretic). 1 If still uncontrolled with three drugs at maximum tolerated doses, add spironolactone (mineralocorticoid receptor antagonist) or other fourth-line agent. 1

Beta-blockers should be combined with other BP-lowering drugs when specific indications exist: angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control. 1

Blood Pressure Targets

Target systolic BP: 120-129 mmHg 1 Target diastolic BP: 70-79 mmHg 1

These targets apply to most patients if tolerated. 1 Achieve target within 3 months of initiating or modifying therapy to maintain patient confidence and reduce CVD risk. 1

Special Population Targets

• Diabetes: Systolic BP 120-129 mmHg 1
• CKD with eGFR >30 mL/min/1.73 m²: Systolic BP 120-129 mmHg 1
• History of stroke/TIA: Systolic BP 120-129 mmHg 1
• Pregnancy (chronic or gestational hypertension): <140/90 mmHg but not <80 mmHg diastolic 1

Essential Diagnostic Workup

Before or shortly after starting treatment, obtain: 1

• Serum creatinine, eGFR, and urine albumin:creatinine ratio (repeat annually if moderate-to-severe CKD) 1
• 12-lead ECG (all patients) 1
• Echocardiography if ECG abnormalities or cardiac symptoms present 1
• Screen for secondary hypertension if suggestive signs/symptoms present 1

Screening for Secondary Causes

Consider secondary hypertension screening in: 1

• Young adults (<40 years) with hypertension, especially if non-obese 2
• Resistant hypertension (uncontrolled on 3+ drugs) 1
• Sudden onset or worsening hypertension 1
• Hypokalemia or hyperkalemia 1

Primary aldosteronism screening (renin and aldosterone levels) should be considered in all adults with confirmed BP ≥140/90 mmHg. 2

Medication Timing and Adherence

Take medications at the most convenient time of day to improve adherence—current evidence shows no benefit of specific diurnal timing on CVD outcomes. 1 Encourage taking medications at the same time daily in a consistent setting. 1

Substances That Elevate Blood Pressure

Review and discontinue or reduce when possible: 1

• NSAIDs (consider acetaminophen, tramadol, or topical NSAIDs as alternatives) 1
• Decongestants (use nasal saline, intranasal corticosteroids, or antihistamines instead) 1
• Oral contraceptives (use lowest dose or progestin-only formulations) 1
• Amphetamines and stimulants 1
• Certain antidepressants (SNRIs, MAOIs, TCAs) 1
• Excessive alcohol or caffeine 1

Monitoring and Follow-Up

• Before starting/intensifying medications: Test for orthostatic hypotension (measure BP after 5 min sitting/lying, then at 1 and/or 3 min after standing) 1
• Initial follow-up: Reassess within 2-4 weeks after initiating or adjusting therapy 2
• Once controlled: At least annual follow-up for BP and cardiovascular risk factors 2
• Monitor labs: Serum creatinine/eGFR and potassium when using ACE inhibitors, ARBs, or diuretics 2

Patient-Centered Care

• Conduct informed discussions about CVD risk and treatment benefits tailored to individual patient needs 1
• Implement home BP self-monitoring to improve BP control and treatment adherence 1
• Consider multidisciplinary approaches including nurse-led care or teleconsultation in appropriate healthcare systems 1