What are the guidelines for managing hypertension?

Hypertension Management Guidelines

Diagnosis and Blood Pressure Measurement

Hypertension should be diagnosed using validated devices with the patient seated, arm at heart level, taking at least two measurements per visit 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 (HBPM) is the most practical method for medication titration and is more sensitive than office readings for detecting masked hypertension. 3

• Routine investigations should include urine testing for blood and protein, blood electrolytes and creatinine, blood glucose, serum cholesterol, and 12-lead ECG. 2, 3

• Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions using validated risk calculators. 2, 3

Blood Pressure Classification

• Normal: <120/80 mmHg 1
• Prehypertension/Elevated: 130-139/80-89 mmHg 1
• Stage 1 Hypertension: 140-159/90-99 mmHg 1
• Stage 2 Hypertension: ≥160/100 mmHg 1

Treatment Thresholds

All patients with sustained BP ≥160/100 mmHg require immediate drug therapy regardless of cardiovascular risk. 2, 3

• For BP 140-159/90-99 mmHg, initiate drug therapy if any of the following are present: 2, 3

  • Target organ damage
  • Established cardiovascular disease
  • Diabetes mellitus
  • 10-year cardiovascular disease risk ≥20%

• For BP ≥180/110 mmHg, urgent treatment is needed. 1, 2

• For patients >80 years, the European Society of Cardiology recommends initiating treatment only when office SBP ≥160 mmHg. 4

Blood Pressure Targets

For most non-diabetic patients, target BP is ≤140/85 mmHg. 1, 2, 3

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

• When using ambulatory or home BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents. 2

• For adults ≥65 years, target SBP <130 mmHg if tolerated. 5

Lifestyle Modifications

All patients with hypertension or elevated blood pressure should receive lifestyle modification recommendations, which can lower systolic BP by approximately 5 mmHg per intervention. 1, 2, 3

Specific Interventions with Expected Benefits:

• Weight loss: Approximately 1 mmHg SBP reduction per 1 kg weight loss; achieving ideal body weight is recommended. 3

• DASH diet: Emphasizing fruits, vegetables, whole grains, low-fat dairy products with reduced saturated fat can reduce SBP by ~5 mmHg. 3

• Sodium restriction: Optimal goal <1500 mg/day can reduce SBP by 1-3 mmHg per 1000 mg decrease in sodium intake. 3

• Physical activity: Aerobic exercise 5-7 times/week for 30-60 minutes/session can reduce SBP by ~5 mmHg. 3

• Alcohol moderation: Men ≤2 standard drinks/day and women ≤1 standard drink/day can reduce SBP by ~4 mmHg. 3

• Potassium supplementation: Optimal goal 3500-5000 mg/day can reduce SBP by ~5 mmHg. 3

• Smoking cessation is recommended for cardiovascular disease prevention. 4

Pharmacological Management

Most patients with hypertension require at least two blood pressure lowering drugs to achieve recommended goals; fixed-dose combinations are preferred as initial therapy. 3

First-Line Drug Therapy:

The preferred initial approach is fixed-dose combination therapy combining a renin-angiotensin system (RAS) blocker with either a dihydropyridine calcium channel blocker or thiazide-like diuretic. 1, 3

• First-line agents include: 1, 2, 5
  • Thiazide or thiazide-like diuretics (chlorthalidone preferred) 3
  • ACE inhibitors or ARBs
  • Calcium channel blockers (amlodipine as first-line) 3

Medication Titration Algorithm:

1. Start with combination therapy (RAS blocker + CCB or diuretic) 1, 3
2. If BP not controlled, add third agent from remaining first-line class 2
3. If still uncontrolled, consider beta-blocker, alpha-blocker, aldosterone antagonist, direct vasodilator, or centrally acting alpha-2 agonist 6

• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence. 1, 3

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%. 3

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. 3

• Target for statin therapy: 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. 3

Special Populations

• Elderly patients (≥80 years): Treatment should be maintained if well tolerated. 1

• Patients with diabetes, renal impairment, or established CVD: Lower BP target of ≤130/80 mmHg. 1, 2, 3

• Pregnancy: Requires specialized management protocols. 2

Secondary Hypertension Screening

Secondary hypertension should be suspected in the following scenarios: 2

• Elevated serum creatinine or proteinuria/hematuria
• Sudden onset or worsening of hypertension
• Resistance to multiple drugs
• Young age at presentation
• Electrolyte abnormalities suggesting endocrine causes

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis 2

• Not considering white coat hypertension when office readings are elevated 2

• Inadequate dosing or inappropriate combinations of antihypertensive medications 2

• Not addressing lifestyle modifications alongside pharmacological treatment 2

• Overlooking the need for lower BP targets in high-risk patients (diabetes, CKD, established CVD) 2

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

• Underutilizing combination therapy when most patients require at least two agents 3

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. 1, 3

• Monitor for adverse effects of medications and adjust therapy as needed. 2, 3

• Home blood pressure monitoring should be encouraged for medication titration. 3