What are the guidelines for managing hypertension (HTN) in an adult patient?

Management of Hypertension in Adults

For most adults with hypertension, initiate treatment with a two-drug combination (preferably as a single-pill combination) consisting of a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker (amlodipine preferred) or a thiazide-like diuretic (chlorthalidone or indapamide preferred), targeting a blood pressure of <130/80 mm Hg for adults under 65 years and <130 mm Hg systolic for those 65 and older. 1, 2

Blood Pressure Classification and Treatment Thresholds

Elevated BP (120-129/<80 mm Hg):

• Initiate lifestyle modifications only 1
• Repeat BP evaluation within 3-6 months if 10-year ASCVD risk <10% 1

Stage 1 Hypertension (130-139/80-89 mm Hg):

• If 10-year ASCVD risk <10%: lifestyle modifications alone with repeat evaluation in 3-6 months 1
• If 10-year ASCVD risk ≥10%: combination of lifestyle modifications plus antihypertensive medication, with repeat evaluation in 1 month 1
• European guidelines recommend pharmacological treatment after 3 months of lifestyle intervention for BP ≥130/80 mm Hg with high CVD risk 2

Stage 2 Hypertension (≥140/90 mm Hg):

• Initiate combination therapy with two antihypertensive agents from different classes plus lifestyle modifications 1
• Evaluate or refer to primary care within 1 month 1
• Repeat BP evaluation in 1 month 1

Severe Hypertension (SBP ≥180 or DBP ≥110 mm Hg):

• Prompt evaluation and immediate antihypertensive treatment required 1
• Treatment should be initiated within 1 week maximum 1

Initial Pharmacological Treatment Strategy

First-Line Combination Therapy (preferred for most patients):

• ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB plus amlodipine 5 mg daily 1, 2, 3, 4
• Alternatively: ACE inhibitor or ARB plus chlorthalidone or indapamide 1, 2, 5
• Single-pill combinations strongly favored to improve adherence 1, 2

Monotherapy considerations:

• Reserved only for Stage 1 hypertension with low cardiovascular risk 1
• Starting dose for lisinopril monotherapy: 10 mg once daily, adjustable to 20-40 mg daily 3
• Starting dose for amlodipine monotherapy: 5 mg once daily, adjustable to 10 mg daily 4

Special population - Black patients:

• Initiate with thiazide-like diuretic plus calcium channel blocker, or calcium channel blocker plus ARB 1
• ARBs preferred over ACE inhibitors due to 3-fold higher risk of angioedema with ACE inhibitors 1

Blood Pressure Targets

Adults <65 years:

• Target: <130/80 mm Hg 1
• Optimal target per European guidelines: 120-129/<80 mm Hg if well tolerated 2

Adults ≥65 years:

• Target: SBP <130 mm Hg for noninstitutionalized, ambulatory, community-living older adults 1
• For those with high comorbidity burden or limited life expectancy, base treatment intensity on clinical judgment and patient preference 1
• If target cannot be achieved due to poor tolerance, aim for "as low as reasonably achievable" (ALARA principle) 2

Adults aged 60+ years (alternative approach):

• ACP/AAFP guidelines suggest SBP target <150 mm Hg is reasonable 1
• Consider intensifying to <140 mm Hg for high cardiovascular risk patients based on individualized assessment 1

Lifestyle Modifications (Essential for All Patients)

Weight management:

• Achieve and maintain healthy body mass index 1, 5, 6
• Weight loss is among the most effective lifestyle interventions 6

Dietary modifications:

• DASH diet (Dietary Approaches to Stop Hypertension) - most effective dietary intervention 6
• Sodium restriction to <2,300 mg/day, ideally <1,500 mg/day 1, 5, 6
• Increased potassium intake through diet 1, 5, 6
• Consume fresh rather than processed foods 7

Physical activity:

• Regular aerobic exercise recommended 1, 5, 6

Alcohol moderation:

• Limit to ≤2 standard drinks/day for men (maximum 14/week) 1, 5, 6
• Limit to ≤1 standard drink/day for women (maximum 9/week) 1, 6

Tobacco cessation:

• Crucial for CVD risk reduction 1

Stress management:

• Individualized cognitive-behavioral modification in appropriate circumstances 1, 8

Medication Titration and Follow-Up

If BP remains above goal on initial two-drug combination:

• Switch to single-pill combination of ACE inhibitor or ARB plus calcium channel blocker plus thiazide-like diuretic 1

If BP still above goal on three-drug combination:

• Add spironolactone (preferred fourth agent) 1
• Alternative fourth agents: other diuretic, alpha-blocker, or beta-blocker 1
• Consider referral to specialist center 1

Follow-up schedule:

• Stage 1 hypertension with low ASCVD risk: 3-6 months 1
• Stage 1 hypertension with high ASCVD risk or Stage 2: 1 month 1
• Once BP controlled and stable: yearly follow-up 2
• Normal BP: annual screening 1

Adherence optimization:

• Use once-daily dosing (adherence 71-94% vs. lower with multiple daily doses) 1
• Prescribe single-pill combination therapy whenever possible 1, 2
• Create blame-free environment to identify barriers to adherence 1
• Use objective adherence measures (pill counts, refill data) alongside self-report 1

Diagnostic Confirmation

Before initiating treatment:

• Confirm diagnosis with accurate office BP measurements 2
• Obtain home BP monitoring or ambulatory BP monitoring to exclude white coat hypertension 2
• This is particularly important for Stage 1 hypertension with low ASCVD risk 1

For adults diagnosed before age 40:

• Comprehensive screening for secondary causes of hypertension is mandatory (except obese young adults where sleep apnea evaluation should be performed first) 2

Baseline evaluation:

• Calculate 10-year ASCVD risk to guide treatment decisions 2
• Screen for hypertension-mediated organ damage (heart, kidneys, blood vessels, eyes) 2

Critical Pitfalls to Avoid

Medication combinations:

• Never combine two RAS blockers (ACE inhibitor plus ARB) - potentially harmful 1, 2
• Never use ACE inhibitor, ARB, and renin inhibitor simultaneously 1

Adherence issues:

• Up to 25% of patients don't fill initial prescriptions 2
• Only 1 in 5 patients has sufficiently high adherence 2
• Address this proactively with once-daily dosing and combination pills 2

Diagnostic errors:

• Do not rely solely on office BP measurements without home or ambulatory monitoring 2
• Failure to screen for secondary causes in young adults (<40 years) with hypertension 2

Beta-blocker perioperative management:

• Do not start beta-blockers on the day of surgery in beta-blocker-naive patients 1

Team-Based Care Approach

Implementation strategies:

• Utilize multidisciplinary team-based care 1, 2
• Employ electronic health records and telehealth strategies 2
• Use community health workers, particularly for resource-constrained populations 1
• Implement motivational interviewing, goal setting, self-monitoring, and feedback 1

For resource-constrained populations:

• Address health literacy barriers 1
• Partner with community resources and organizations 1
• Consider out-of-office BP monitoring or no-cost BP control visits 1
• Health system financing strategies (insurance coverage, copayment benefit design) improve medication adherence 1