What are the current guidelines for managing hypertension?

Current Hypertension Management Guidelines

Diagnosis and Blood Pressure Thresholds

Hypertension is diagnosed when office blood pressure reaches ≥140/90 mmHg, confirmed by out-of-office measurements showing home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg. 1, 2

• Use validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms at the first visit and using the arm with higher readings for subsequent measurements 1
• Record two or more blood pressures at each visit and assess thresholds on several occasions before confirming diagnosis 2
• Measure standing pressures in elderly patients and those with diabetes to detect orthostatic hypotension 2

Blood pressure classification: 2

• Non-elevated BP: <120/70 mmHg
• Elevated BP: 120-139/70-89 mmHg
• Grade 1 Hypertension: 140-159/90-99 mmHg
• Grade 2 Hypertension: ≥160/100 mmHg

Treatment Initiation Strategy

For confirmed hypertension (≥140/90 mmHg), start both pharmacological therapy and lifestyle modifications immediately—do not delay drug treatment while attempting lifestyle changes alone. 2

• For elevated BP (120-139/70-89 mmHg), start pharmacological therapy immediately if the patient has high cardiovascular risk, 10-year CVD risk ≥10%, or risk modifiers 2
• For Grade 1 Hypertension with low-moderate risk, begin drug therapy after 3-6 months of lifestyle intervention only if BP remains elevated 1
• For Grade 2 Hypertension, start immediate drug treatment alongside lifestyle interventions for all patients 1

Pharmacological Treatment Algorithm

Start with two-drug combination therapy as initial treatment for confirmed hypertension (≥140/90 mmHg), preferably as a single-pill combination to improve adherence. 2, 1

For Non-Black Patients:

• First-line: RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker, OR RAS blocker + thiazide/thiazide-like diuretic 2, 1
• Start with low-dose and increase to full dose if needed 1

For Black Patients:

• First-line: ARB + dihydropyridine calcium channel blocker, OR dihydropyridine calcium channel blocker + thiazide-like diuretic 1
• Calcium channel blockers and thiazide diuretics are more effective as initial therapy than RAS blockers in this population 1

Monotherapy Considerations:

• Consider monotherapy only in low-risk Grade 1 hypertension and in patients >80 years or frail 1

Medication Escalation:

• If BP remains uncontrolled, add a third agent from the remaining first-line classes 1
• Beta-blockers should be used when there are specific indications: coronary artery disease, heart failure, or for heart rate control 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB together) 1

Blood Pressure Targets

Target BP is <130/80 mmHg for most patients, with a minimum acceptable target of <140/90 mmHg. 2, 1

• For adults <65 years: <130/80 mmHg 3
• For adults ≥65 years: systolic <130 mmHg 3
• For patients with diabetes or chronic kidney disease: <130/80 mmHg 1
• The European Society of Cardiology recommends targeting systolic BP of 120-129 mmHg in most adults, if well tolerated 1
• Aim to reduce BP by at least 20/10 mmHg from baseline 1
• Achieve target BP within 3 months 1

Elderly and Frail Patients:

• Individualize targets based on frailty, but do not automatically accept higher targets 2, 1
• Consider starting with lower doses and more gradual BP reduction in patients >80 years 1

Lifestyle Modifications

Lifestyle modifications provide additive BP reductions of 10-20 mmHg and should be implemented alongside pharmacological therapy. 2

Dietary Sodium:

• Restrict dietary sodium intake to <100 mmol/day for prevention 1
• Limit to 65-100 mmol/day in hypertensive patients 1

Weight Management:

• Maintain healthy body weight with BMI 18.5-24.9 kg/m² 1
• Maintain waist circumference <102 cm in men and <88 cm in women 1

Physical Activity:

• Perform 150 minutes/week of moderate aerobic exercise (or 30-60 minutes, 4-7 days per week) 1

Alcohol Limitation:

• Limit consumption to <21 units/week for men and <14 units/week for women 1

Dietary Pattern:

• Adopt DASH or Mediterranean diet emphasizing fruits, vegetables, low-fat dairy products, dietary fiber, whole grains, and plant-based protein 1, 2
• Reduce saturated fat and cholesterol 1

Smoking Cessation:

• Mandatory recommendation for all patients 1, 2

Special Populations

Diabetes:

• Target BP <130/80 mmHg 1
• Use RAS inhibitor plus calcium channel blocker and/or thiazide-like diuretic 1

Chronic Kidney Disease:

• Use RAS inhibitors as first-line therapy 1
• Target BP <130/80 mmHg 1

Coronary Artery Disease:

• Consider beta-blockers and RAS inhibitors as first-line therapy 1

Cerebrovascular Disease:

• Prefer ACE inhibitor plus diuretic combination 1

Heart Failure or Recent Myocardial Infarction:

• Use beta-blockers and ACE inhibitors as first-line therapy 1

Monitoring and Follow-Up

See patients every 1-3 months until BP is controlled, and reassess within 2-4 weeks after medication changes. 2

• Monitor BP control and achieve target within 3 months 1
• Check medication adherence regularly, as non-adherence is the most common cause of apparent treatment resistance 2
• If BP remains uncontrolled despite optimal therapy, refer to a specialist with hypertension expertise 1

Key Pitfalls to Avoid

• Do not delay pharmacological therapy while attempting lifestyle modifications alone in confirmed hypertension 2
• Do not combine two RAS blockers (ACE inhibitor + ARB) 1
• Do not start with monotherapy in most patients—combination therapy is now the standard initial approach 2
• Do not assume higher BP targets are acceptable in elderly patients without assessing frailty 2
• Always verify medication adherence before escalating therapy 2