What are the guidelines for a provider in managing a patient's hypertension?

Guidelines for Managing Hypertension

Providers should diagnose hypertension using out-of-office blood pressure monitoring (home or ambulatory BP) whenever possible, initiate treatment based on cardiovascular risk stratification, and target blood pressure goals of <130/80 mmHg for most patients using a stepwise pharmacologic approach starting with ACE inhibitors/ARBs, calcium channel blockers, or thiazide diuretics. 1

Blood Pressure Measurement and Diagnosis

Proper Measurement Technique

• Measure BP after 5 minutes of seated rest with the patient's back supported, legs uncrossed, arm supported at heart level, and bladder emptied 1
• Remove clothing at cuff placement site without rolling up sleeves (creates tourniquet effect) 1
• Use validated automated oscillometric devices with appropriate cuff size for the patient's arm circumference 1
• Measure BP in both arms simultaneously at first visit; consistently use the arm with higher readings 1

Diagnostic Thresholds

• For screening BP 120-139/70-89 mmHg with increased CVD risk: confirm with out-of-office monitoring (ABPM or home BP) 1
• For screening BP 140-159/90-99 mmHg: diagnose hypertension based on out-of-office measurements showing home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 1
• For screening BP 160-179/100-109 mmHg: confirm within 1 month using home or ambulatory monitoring 1
• For screening BP ≥180/110 mmHg: exclude hypertensive emergency immediately 1

Cardiovascular Risk Assessment

Use SCORE2 for patients aged 40-69 years and SCORE2-OP for patients ≥70 years to assess 10-year CVD risk, unless already at increased risk from moderate-to-severe CKD, established CVD, hypertension-mediated organ damage, diabetes, or familial hypercholesterolemia 1

• Patients with SCORE2 or SCORE2-OP ≥10% are considered at increased CVD risk regardless of age 1

Initial Evaluation

Required Laboratory Tests

• Measure serum creatinine, eGFR, and urine albumin-to-creatinine ratio (ACR) in all hypertensive patients 1
• Repeat creatinine, eGFR, and urine ACR at least annually if moderate-to-severe CKD is present 1
• Obtain 12-lead ECG for all hypertensive patients 1

Additional Testing When Indicated

• Perform echocardiography if ECG abnormalities present or signs/symptoms of cardiac disease 1
• Perform fundoscopy if BP >180/110 mmHg to evaluate for hypertensive emergency/malignant hypertension, or in diabetic hypertensive patients 1
• Screen for secondary hypertension when suggestive signs, symptoms, or medical history present 1

Lifestyle Modifications (All Patients)

Dietary Interventions

• Restrict sodium to approximately 2 g/day (equivalent to 5 g salt/day or one teaspoon) 1
• Adopt Mediterranean or DASH dietary pattern 1
• Restrict free sugar to maximum 10% of energy intake; discourage sugar-sweetened beverages 1

Physical Activity

• Prescribe moderate-intensity aerobic exercise ≥150 minutes/week (30 minutes, 5-7 days/week) or 75 minutes vigorous exercise/week over 3 days 1
• Add low- or moderate-intensity resistance training 2-3 times/week 1

Weight and Alcohol Management

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Limit alcohol to <100 g/week of pure alcohol; preferably avoid completely for best health outcomes 1

Tobacco Cessation

• Stop all tobacco use and refer to smoking cessation programs 1

Pharmacologic Treatment Initiation

When to Start Medications

• Immediately in high-risk patients (CVD, CKD, diabetes, or organ damage) with BP 140-159/90-99 mmHg 1
• After 3-6 months of lifestyle intervention in low-moderate risk patients with persistent BP ≥140/90 mmHg 1

First-Line Drug Selection

Non-Black Patients

Step 1: Start low-dose ACE inhibitor or ARB 1, 2

• ACE inhibitors/ARBs are preferred for patients with CKD, heart failure, diabetes, or coronary artery disease 2

Step 2: Add dihydropyridine calcium channel blocker (e.g., amlodipine) 1

Step 3: Increase both agents to full dose 1

Step 4: Add thiazide or thiazide-like diuretic 1

• Chlorthalidone preferred over hydrochlorothiazide for resistant hypertension (provides greater 24-hour BP reduction) 2

Black Patients

Step 1: Start low-dose ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide/thiazide-like diuretic 1, 2

Step 2: Increase to full dose 1

Step 3: Add diuretic or ACE inhibitor/ARB (whichever not yet included) 1

Blood Pressure Targets

Target BP <130/80 mmHg for most adults <65 years; target systolic BP <130 mmHg for adults ≥65 years 1

• Individualize targets for elderly based on frailty 1
• Achieve target BP within 3 months of treatment initiation or modification 1, 2
• Reassess BP within 2-4 weeks after adding or adjusting medications 2

Resistant Hypertension Management

Definition and Evaluation

Resistant hypertension = BP remains uncontrolled despite optimal doses of 3 antihypertensive agents (including a diuretic) 1, 3

Common Causes to Address

• Poor medication adherence (most common cause) 1
• Obstructive sleep apnea 1
• Volume overload from excessive salt intake, inadequate diuretic therapy, or progressing renal insufficiency 1
• Secondary hypertension causes 1
• White-coat hypertension (confirm with ambulatory monitoring) 1
• Interfering substances: NSAIDs, alcohol, sympathomimetics 1, 2

Fourth-Line Agent

Add spironolactone 25-50 mg daily as preferred fourth-line agent for resistant hypertension 1, 2

• Spironolactone lowers BP by average 25/12 mmHg when added to multidrug regimens 2
• Monitor serum potassium and creatinine closely, especially with concurrent ACE inhibitor/ARB use 1

Alternative Fourth-Line Agents

If spironolactone not tolerated or contraindicated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Special Diuretic Considerations

Use loop diuretics instead of thiazides when creatinine clearance <30 mL/min 2

Patient-Centered Care Strategies

Self-Monitoring

• Home BP self-monitoring is recommended to achieve better BP control and enhance treatment adherence 1
• Self-measurement improves acceptance of hypertension diagnosis and patient empowerment 1

Multidisciplinary Approaches

• Multidisciplinary management with appropriate task-shifting away from physicians is recommended to improve BP control 1
• Consider motivational interviewing at hospitals and community health centers to assist BP control and enhance adherence 1
• Physician-patient web communications for reporting home BP readings should be considered in primary care 1

Hypertensive Emergencies

In intracerebral hemorrhage with systolic BP ≥220 mmHg, do not reduce systolic BP >70 mmHg from initial levels within 1 hour of treatment 1

Referral Criteria

Refer to hypertension specialist if BP remains uncontrolled despite optimized therapy or other management issues arise 1