What are the guidelines for managing hypertension?

Hypertension Management Guidelines

For most patients with hypertension, initiate drug therapy 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 <140/85 mmHg for most patients and <130/80 mmHg for those with diabetes, chronic kidney disease, or established cardiovascular disease. 1, 2, 3

Diagnosis and Blood Pressure Measurement

• Measure BP with a validated device, patient seated with arm at heart level, taking at least two measurements at each of several visits before confirming diagnosis. 4, 1, 2

• Deflate the cuff at 2 mm/s and record BP to the nearest 2 mm Hg, with diastolic pressure recorded as disappearance of sounds (phase V). 4

• Use ambulatory blood pressure monitoring (ABPM) when clinic BP shows unusual variability, hypertension is resistant to ≥3 drugs, symptoms suggest hypotension, or to diagnose white coat hypertension. 4, 1, 2

• When using ambulatory or home BP readings, expect values approximately 10/5 mmHg lower than office readings for both thresholds and targets. 4, 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

Initial Evaluation

• Perform routine investigations including urine strip test for blood and protein, blood electrolytes and creatinine, blood glucose, serum total:HDL cholesterol ratio, and 12-lead ECG. 4, 1, 2

• Calculate formal 10-year cardiovascular disease risk to guide treatment decisions. 1, 2

• Assess for secondary causes, target organ damage, cardiovascular risk factors, and comorbid diseases that influence treatment. 4

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:

• Initiate drug therapy for all patients with sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg despite non-pharmacological measures. 4, 1, 2

• For sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg, initiate treatment if any of the following are present: target organ damage, established cardiovascular disease, diabetes mellitus, or 10-year cardiovascular disease risk ≥20%. 4, 1, 2

Blood Pressure Targets

• For most non-diabetic patients, target BP <140/85 mmHg (minimum acceptable audit standard <150/90 mmHg). 4, 2, 3

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

• The HOT trial demonstrated optimal BP for reduction of major cardiovascular events was 139/83 mmHg, with no harm from lowering below this level, though patients between 139/83 and 150/90 mmHg were not disadvantaged. 4

Lifestyle Modifications

All patients with hypertension, borderline, or high-normal BP should receive lifestyle modification recommendations, which can lower systolic BP by approximately 5 mmHg per intervention. 4, 2, 5

Effective interventions include:

• Weight reduction to achieve ideal body weight (BMI 18.5-24.9 kg/m²), which reduces SBP by approximately 1 mmHg per 1 kg weight loss. 4, 2

• Regular aerobic physical activity 5-7 times/week for 30-60 minutes/session (brisk walking rather than isometric weight training), reducing SBP by ~5 mmHg. 4, 2

• Sodium restriction with optimal goal <1500 mg/day (65-100 mmol/day for hypertensive patients), reducing SBP by 1-3 mmHg per 1000 mg decrease. 4, 2

• Alcohol moderation: ≤2 standard drinks/day for men (≤14 units/week) and ≤1 standard drink/day for women (≤9 units/week), reducing SBP by ~4 mmHg. 4, 2

• DASH diet emphasizing fruits, vegetables, whole grains, low-fat dairy products with reduced saturated and total fat, reducing SBP by ~5 mmHg. 4, 2

• Potassium supplementation with optimal goal 3500-5000 mg/day, reducing SBP by ~5 mmHg. 2

• Smoking cessation to further reduce cardiovascular disease risk. 4

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

Pharmacological Management

First-line drug therapy includes thiazide or thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs). 1, 3, 6, 7, 5

• Most patients will require at least two BP-lowering drugs to achieve recommended goals; fixed-dose combinations are preferred when no cost disadvantages exist. 2

• Preferred combinations include a renin-angiotensin system (RAS) blocker with either a dihydropyridine calcium channel blocker or thiazide-like diuretic. 2, 3

• Chlorthalidone is the preferred thiazide-like diuretic based on clinical trial data. 2, 5

• Amlodipine is recommended as the first-line calcium channel blocker. 2, 6

• Amlodipine may be used alone or in combination with other antihypertensive agents and lowers BP by reducing peripheral vascular resistance. 6

• Lisinopril (ACE inhibitor) is indicated for hypertension treatment and may be administered alone or with other antihypertensive agents. 7

• Beta-blockers are appropriate for first-line therapy in patients younger than 60 years of age. 2

Adjunctive 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

Indications for Specialist Referral

Refer to specialist for:

• Urgent treatment needs: malignant hypertension or impending complications 4
• Suspected secondary causes: elevated serum creatinine, proteinuria/hematuria, sudden onset or worsening hypertension, resistance to ≥3 drugs, young age (<30 years needing treatment), or electrolyte abnormalities suggesting Conn's syndrome 4, 1
• Therapeutic problems or failures 4
• Special circumstances: unusually variable BP, possible white coat hypertension, pregnancy 4, 1

Monitoring and Follow-up

• Regular BP monitoring using both office and home readings is necessary for optimal management. 2, 3

• Annual reassessment of cardiovascular risk is recommended. 2, 3

• Monitor for adverse effects of medications and adjust therapy as needed. 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 at several visits before initiating treatment. 1

• Not considering white coat hypertension when office readings are elevated—use ABPM or home monitoring. 1

• Inadequate dosing or inappropriate combinations of antihypertensive medications. 1

• Not addressing lifestyle modifications alongside pharmacological treatment, which can reduce medication requirements. 1

• Overlooking the need for lower BP targets (<130/80 mmHg) in high-risk patients with diabetes, chronic kidney disease, or established cardiovascular disease. 1, 2

• Not considering secondary causes in resistant hypertension (≥3 drugs) or young patients (<30 years). 1