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, renal impairment, or established cardiovascular disease. 1, 2, 3

Blood Pressure Measurement and Diagnosis

Proper measurement technique is essential to avoid misdiagnosis:

• Measure BP with a validated device, patient seated with arm at heart level, cuff deflated at 2 mm/s, recording to the nearest 2 mmHg, with diastolic pressure at disappearance of sounds (phase V) 1, 2
• Take at least two measurements at each of several visits before confirming diagnosis and initiating treatment 1, 2, 3
• Use ambulatory blood pressure monitoring (ABPM) when clinic BP shows unusual variability, hypertension is resistant to three or more drugs, symptoms suggest hypotension, or to diagnose white coat hypertension 1, 2, 3
• ABPM and home BP readings are expected to be approximately 10/5 mmHg lower than office readings 1, 3

Initial Evaluation

All hypertensive patients require targeted assessment to identify secondary causes, cardiovascular risk, and target organ damage:

• Urine strip test for blood and protein 1, 2
• Blood electrolytes and creatinine 1, 2
• Blood glucose 1, 2
• Serum total:HDL cholesterol ratio 1, 2
• 12-lead electrocardiograph 1, 2
• Formal estimation of 10-year cardiovascular disease risk 2, 3

Treatment Thresholds

Treatment decisions follow a risk-stratified approach:

• Urgent treatment required: Accelerated hypertension (severe hypertension with grade III-IV retinopathy), BP >220/120 mmHg, or impending complications such as transient ischemic attack or left ventricular failure 1, 2
• Immediate drug therapy: Sustained BP ≥160/100 mmHg despite non-pharmacological measures 1, 2, 3
• Drug therapy for moderate elevation (140-159/90-99 mmHg): Initiate if target organ damage present, established cardiovascular disease, diabetes mellitus, or 10-year CVD risk ≥20% 1, 2, 3
• Lifestyle modifications alone for 6 months: Grade 1 (mild) hypertension without complications or target organ damage 1

Blood Pressure Targets

Lower targets reduce cardiovascular events in high-risk populations:

• Standard target: ≤140/85 mmHg for most patients (minimum audit standard <150/90 mmHg) 1, 2, 3
• Intensive target: ≤130/80 mmHg for patients with diabetes, chronic kidney disease, or established cardiovascular disease 1, 2, 3
• The HOT trial demonstrated optimal BP of 139/83 mmHg for cardiovascular event reduction, with no harm from lower pressures 1

Lifestyle Modifications

All patients with hypertension or high-normal BP should receive comprehensive lifestyle counseling, as these interventions can reduce systolic BP by approximately 5 mmHg per intervention: 3

• Weight reduction: Achieve ideal body weight through reduced fat and total calorie intake; approximately 1 mmHg SBP reduction per 1 kg weight loss 1, 3
• Physical activity: Regular aerobic exercise 5-7 times/week for 30-60 minutes/session (predominantly dynamic such as brisk walking rather than isometric weight training); reduces SBP by ~5 mmHg 1, 3
• Sodium restriction: Optimal goal <1500 mg/day; reduces SBP by 1-3 mmHg per 1000 mg decrease 3
• DASH diet: Emphasize fruits, vegetables, whole grains, low-fat dairy products with reduced saturated and total fat; reduces SBP by ~5 mmHg 3, 4
• Alcohol moderation: Men ≤2 standard drinks/day, women ≤1 standard drink/day (or <21 units/week for men, <14 units/week for women); reduces SBP by ~4 mmHg 1, 3
• Potassium supplementation: Optimal goal 3500-5000 mg/day; reduces SBP by ~5 mmHg 3

Additional cardiovascular risk reduction measures include smoking cessation, reducing saturated fat intake and replacing with polyunsaturated or monounsaturated fats, and increased consumption of oily fish. 1

Pharmacological Management

Most patients require at least two antihypertensive drugs to achieve target BP; fixed-dose combinations are preferred when cost-neutral: 3

First-Line Agents

• Thiazide or thiazide-like diuretics (chlorthalidone preferred) 3, 4
• ACE inhibitors (e.g., lisinopril) or angiotensin receptor blockers (ARBs) 5, 4
• Calcium channel blockers (amlodipine as first-line) 3, 6, 4
• Beta-blockers (when compelling indications exist) 1

Initial Therapy Strategy

• Fixed-dose combinations combining a renin-angiotensin system (RAS) blocker with either a dihydropyridine calcium channel blocker or thiazide-like diuretic are recommended as initial therapy 3
• When no compelling indications exist, follow the AB/CD algorithm for drug selection 1, 2
• Titrate according to office and home BP readings to achieve target 4

Compelling Indications for Specific Drug Classes

The British Hypertension Society guidelines identify specific clinical scenarios requiring particular agents: 1

• ACE inhibitors: Heart failure, left ventricular dysfunction post-MI, established coronary heart disease, type 1 diabetic nephropathy, type 2 diabetic nephropathy, chronic renal disease, secondary stroke prevention 1
• ARBs: ACE inhibitor intolerance, type 2 diabetic nephropathy, left ventricular dysfunction after MI 1
• Alpha-blockers: Benign prostatic hypertrophy 1

Contraindications to Note

• ACE inhibitors/ARBs: Pregnancy, renovascular disease (compelling contraindication); renal impairment, peripheral vascular disease (caution) 1
• Alpha-blockers: Urinary incontinence (compelling contraindication); postural hypotension, heart failure (caution) 1

Adjunctive Cardiovascular Risk Reduction

Beyond BP control, address total cardiovascular risk:

• Aspirin: 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% 3
• Statins: For primary prevention in patients up to at least 80 years with 10-year CVD risk ≥20% and total cholesterol ≥3.5 mmol/L; target 25% reduction in total cholesterol or 30% reduction in LDL cholesterol 3

Resistant Hypertension

Suspect resistant hypertension when BP remains uncontrolled on three or more drugs; systematically evaluate for correctible causes:

• Confirm true resistance by excluding pseudoresistance (white coat hypertension, improper BP measurement technique, medication non-adherence) 7
• Screen for secondary causes: elevated serum creatinine, proteinuria or hematuria, sudden onset or worsening hypertension, young age (<30 years needing treatment), hypokalaemia with increased or high-normal plasma sodium (suggesting Conn's syndrome) 1, 2, 7
• Optimize antihypertensive regimen with drugs having complementary mechanisms of action at optimal doses 7
• Mineralocorticoid receptor antagonists are highly effective as fourth-line agents, even without biochemical evidence of aldosterone excess 7

Specialist Referral Indications

Refer promptly when:

• Malignant hypertension or impending complications requiring urgent treatment 1, 2
• Initial evaluation suggests secondary causes (any clue in history/examination, hypokalaemia with elevated sodium, elevated creatinine, proteinuria/hematuria, sudden onset, resistance to ≥3 drugs, young age) 1, 2
• Therapeutic problems or failures 1
• Special circumstances: unusually variable BP, possible white coat hypertension, pregnancy 1, 2

Common Pitfalls to Avoid

• Diagnosing hypertension based on single elevated reading rather than confirming with multiple measurements over several visits 2, 3
• Missing white coat hypertension by not considering ABPM when office readings are elevated but clinical picture doesn't fit 2, 3
• Inadequate medication dosing or inappropriate combinations rather than using complementary mechanisms of action 2, 3
• Neglecting lifestyle modifications when initiating pharmacotherapy; these interventions are additive with drug effects 2, 3
• Using standard BP targets (<140/85 mmHg) in high-risk patients (diabetes, CKD, established CVD) who require more intensive targets (<130/80 mmHg) 1, 2, 3
• Failing to investigate secondary causes in resistant hypertension, young patients, or those with suggestive clinical features 2, 3
• Not addressing total cardiovascular risk including lipids, diabetes management, and antiplatelet therapy when indicated 3

Monitoring and Follow-up

• Regular BP monitoring using both office and home readings for optimal management 2, 3
• Annual reassessment of cardiovascular disease risk 2, 3
• Monitor for adverse medication effects and adjust therapy accordingly 2, 3
• Medications should be taken at the most convenient time of day to establish habitual patterns and improve adherence 3