What are the latest guidelines for anti-hypertensive therapy?

Latest Guidelines for Antihypertensive Therapy

For most adults with hypertension, initiate combination therapy with an ACE inhibitor or ARB plus a calcium channel blocker or thiazide diuretic, targeting blood pressure <130/80 mmHg, with treatment algorithms varying by race and comorbidities. 1, 2

Blood Pressure Targets

• Target blood pressure is <130/80 mmHg for most adults under 80 years of age, with a more lenient target of <140/90 mmHg acceptable for elderly patients (>80 years) or those who are frail. 3, 1, 2
• The optimal range is 120-129/70-79 mmHg if well tolerated, though systolic blood pressure should not drop below 120 mmHg. 3, 2
• For patients with coronary artery disease, previous stroke, heart failure, or chronic kidney disease, maintain targets <130/80 mmHg (or <140/80 mmHg in elderly patients). 3

Diagnosis and Confirmation

• Hypertension is diagnosed when office blood pressure measurements are consistently ≥140/90 mmHg. 1
• Confirm elevated office readings with home blood pressure monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) before initiating treatment. 1
• Measure blood pressure in both arms at the first visit; use the arm with higher readings for subsequent measurements. 1

Initial Pharmacological Treatment Algorithm

For Non-Black Patients:

1. Start with low-dose ACE inhibitor or ARB 1
2. Increase to full dose if needed 1
3. Add thiazide or thiazide-like diuretic (hydrochlorothiazide 12.5-25mg or chlorthalidone 12.5-25mg daily) 1, 4
4. Add calcium channel blocker (typically amlodipine 5-10mg) if blood pressure remains uncontrolled 1, 2
5. For resistant hypertension, add spironolactone 25-50mg daily as the fourth agent 1, 2

For Black Patients:

1. Start with ARB plus either a dihydropyridine calcium channel blocker OR a calcium channel blocker plus thiazide/thiazide-like diuretic 1
2. The combination of calcium channel blocker plus thiazide diuretic may be more effective than calcium channel blocker plus ARB in Black patients 2

Combination Therapy Approach

• Most patients require two or more medications to achieve blood pressure goals. 3, 1
• For Grade 2 Hypertension (≥160/100 mmHg), initiate two-drug combination therapy immediately rather than starting with monotherapy. 3, 1
• For Grade 1 Hypertension (140-159/90-99 mmHg) in high-risk patients (those with cardiovascular disease, chronic kidney disease, diabetes, organ damage, or aged 50-80 years), initiate drug treatment immediately. 1
• For low-moderate risk patients with Grade 1 Hypertension, try lifestyle modifications for 3-6 months before starting medications if blood pressure remains elevated. 1
• Use fixed-dose single-pill combinations when possible to improve adherence. 2

First-Line Medication Classes

The following drug classes are recommended as first-line therapy 3, 2, 4:

• Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide due to longer duration of action)
• ACE inhibitors or ARBs (angiotensin receptor blockers)
• Dihydropyridine calcium channel blockers (such as amlodipine)

Thiazide-type diuretics should be included in most regimens as they enhance the efficacy of multidrug regimens and remain underutilized despite strong evidence. 3

Lifestyle Modifications (Essential for All Patients)

• Limit sodium intake to <2.3g (100 mEq) per day, which can provide blood pressure reduction of 5-10 mmHg. 2, 4, 5
• Engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise weekly, complemented with resistance training 2-3 times per week. 2
• Follow the DASH diet (rich in whole grains, fruits, vegetables, polyunsaturated fats, and dairy products). 2, 5, 6
• Achieve and maintain healthy body weight (BMI 20-25 kg/m²). 2
• Limit alcohol intake to <14 units/week for men and <8 units/week for women, preferably avoiding alcohol completely. 2
• Stop all tobacco use. 2

Monitoring and Follow-Up

• Aim to achieve target blood pressure within 3 months of treatment initiation. 1
• Check blood pressure within 2-4 weeks of any medication adjustment. 2
• Check serum electrolytes and renal function within 1 month of adding or increasing the dose of diuretics or ACE inhibitors. 1
• Take at least one antihypertensive medication at bedtime to improve 24-hour blood pressure control. 1

Special Populations and Comorbidities

Coronary Artery Disease:

• Use RAS blockers and beta-blockers irrespective of blood pressure levels, with or without calcium channel blockers. 3
• Target <130/80 mmHg (<140/80 in elderly patients). 3

Previous Stroke:

• Use RAS blockers, calcium channel blockers, and diuretics as first-line drugs. 3
• Target <130/80 mmHg (<140/80 in elderly patients). 3

Heart Failure:

• Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists for HFrEF. 3
• Consider angiotensin receptor-neprilysin inhibitor (sacubitril-valsartan) as an alternative to ACE inhibitors or ARBs. 3
• Target <130/80 mmHg but >120/70 mmHg. 3

Chronic Kidney Disease:

• Use RAS blockers as part of the treatment strategy, especially with albuminuria or proteinuria. 3, 2

Critical Pitfalls to Avoid

• Never combine an ACE inhibitor with an ARB due to increased risk of hyperkalemia and renal dysfunction without additional blood pressure benefit. 1, 2
• Do not use beta-blockers as first-line therapy for uncomplicated hypertension unless there are compelling indications (coronary artery disease, heart failure, post-myocardial infarction). 2
• Use caution with thiazide diuretics in patients with a history of gout due to potential for hyperuricemia. 1
• For resistant hypertension, consider replacing hydrochlorothiazide with chlorthalidone, which provides greater 24-hour blood pressure reduction. 1
• Avoid overly aggressive lowering, particularly diastolic blood pressure below 60 mmHg in elderly patients. 2
• Screen for medication nonadherence and secondary causes of hypertension before escalating to four or more medications. 3, 2