What are the guidelines for managing hypertension in patients, including those with a history of cardiovascular disease or kidney disease?

Hypertension Management Guidelines

Blood Pressure Targets and Treatment Thresholds

For patients with cardiovascular disease or chronic kidney disease, initiate antihypertensive therapy immediately at BP ≥130/80 mm Hg with a target of <130/80 mm Hg; for uncomplicated hypertension, start treatment at BP ≥140/90 mm Hg with a target of <140/90 mm Hg. 1, 2, 3

Standard Population Targets

• Initiate drug therapy at sustained BP ≥160/100 mm Hg regardless of risk factors 4
• Initiate drug therapy at BP 140-159/90-99 mm Hg if target organ damage, established cardiovascular disease, diabetes, or 10-year cardiovascular risk ≥20% is present 4
• Target BP <140/90 mm Hg for most patients 4, 3

High-Risk Population Targets (CVD, CKD, Diabetes)

• Initiate therapy immediately at BP ≥130/80 mm Hg 1, 2
• Target BP <130/80 mm Hg 4, 1, 2
• For elderly patients with these conditions, a less aggressive target of <140/80 mm Hg is acceptable 4, 1
• For dialysis patients specifically, target predialysis BP of 140/90 mm Hg is reasonable 1

First-Line Pharmacologic Treatment

Patients with CKD or Diabetes with Albuminuria

Start with ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily) as first-line monotherapy, as these agents reduce albuminuria in addition to lowering BP. 4, 1, 2, 5

Patients with Coronary Artery Disease or Post-MI

Beta-blockers are first-line therapy, with addition of ACE inhibitor or ARB for additional BP control. 1, 6

Patients with Heart Failure with Reduced Ejection Fraction

Use RAS blockers (ACE inhibitors or ARBs), beta-blockers, and mineralocorticoid receptor antagonists; avoid non-dihydropyridine calcium channel blockers (diltiazem/verapamil). 4, 2

Uncomplicated Hypertension

Start with thiazide-like diuretic (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide), ACE inhibitor/ARB, or calcium channel blocker (amlodipine 5-10 mg daily). 2, 6, 7

Treatment Escalation Algorithm

Stage 1 Hypertension (BP 130-159/80-99 mm Hg)

Begin with monotherapy using the comorbidity-specific agent listed above. 1, 2

Stage 2 Hypertension (BP ≥160/100 mm Hg)

Initiate dual-combination therapy immediately using ACE inhibitor/ARB plus calcium channel blocker OR thiazide diuretic. 1, 2, 3

• Fixed-dose single-pill combinations improve adherence and should be used when available 3

Inadequate Response to Dual Therapy

Add a third agent to create triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic. 2

• Example regimen: Lisinopril 40 mg + amlodipine 10 mg + chlorthalidone 25 mg daily 2

Resistant Hypertension (BP ≥140/90 on Triple Therapy)

Before adding a fourth agent, confirm medication adherence, rule out white coat hypertension with home/ambulatory monitoring, and exclude secondary causes (primary aldosteronism, renal artery stenosis, sleep apnea). 2

• Add spironolactone 25-50 mg daily as the preferred fourth-line agent 2
• Monitor potassium closely when combined with ACE inhibitor/ARB 2

Essential Lifestyle Modifications

All patients must receive comprehensive lifestyle therapy regardless of medication status, as these interventions can reduce BP by 10.5/8.2 mm Hg with moderate changes and 18.2/12.8 mm Hg with intensive changes. 4, 2, 7

Specific Recommendations

• Sodium restriction to <1500 mg/day (or reduce by ≥1000 mg/day from current intake) 1, 2, 7
• Potassium supplementation to 3500-5000 mg/day through dietary sources 1, 2
• Weight loss of ≥1 kg if overweight/obese, targeting ideal body weight 4, 2, 7
• Physical activity: 90-150 minutes/week of aerobic exercise 2, 7
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women, with alcohol-free days each week 4, 2, 7
• DASH diet emphasizing fruits, vegetables, whole grains, low-fat dairy, and reduced saturated fat 2, 7
• Smoking cessation is mandatory and provides greater benefit than BP reduction alone in mild hypertension 4

Monitoring Schedule and Follow-Up

Follow up monthly after medication initiation or dose changes until BP target is achieved, with assessment of adherence and response at each visit. 1, 2

• Achieve target BP within 3 months of treatment initiation or modification 2, 3
• Once BP is consistently at target, follow up annually 3

Laboratory Monitoring

Check serum creatinine/eGFR and potassium at baseline, 2-4 weeks after starting/titrating ACE inhibitor/ARB/diuretic, then annually. 2

• Monitor for hyperkalemia especially when using ACE inhibitor/ARB with eGFR <30 mL/min/1.73m² 2

Critical Contraindications and Pitfalls

Never combine ACE inhibitor with ARB, as this increases adverse events without additional benefit. 2

Avoid non-dihydropyridine calcium channel blockers (diltiazem/verapamil) in heart failure with reduced ejection fraction. 1, 2

Beta-blockers are only indicated for specific comorbidities (prior MI, angina, heart failure with reduced EF), not for routine hypertension. 2

In elderly patients, check standing BP to assess for orthostatic hypotension before treatment. 4

Specialist Referral Criteria

Refer to a hypertension specialist if BP ≥140/90 mm Hg despite four-drug therapy at optimal doses, significant renal disease (eGFR <30 mL/min/1.73m²), multiple drug intolerances, or suspected secondary hypertension. 2

Urgent Situations Requiring Immediate Referral

• Accelerated hypertension (severe hypertension with grade III-IV retinopathy) 4
• Particularly severe hypertension (>220/120 mm Hg) 4
• Impending complications (transient ischemic attack, left ventricular failure) 4
• Suspected secondary causes: hypokalaemia with elevated sodium, sudden onset/worsening of hypertension, young age (<30 years needing treatment) 4

Special Populations

Patients with Previous Stroke

Lower BP if ≥140/90 mm Hg to target <130/80 mm Hg (<140/80 in elderly); use RAS blockers, calcium channel blockers, or diuretics as first-line agents. 4

• Lipid-lowering treatment is mandatory with LDL-C target <70 mg/dL (1.8 mmol/L) in ischemic stroke 4
• Antiplatelet treatment is routinely recommended for ischemic stroke but not hemorrhagic stroke 4

Patients with COPD

Use ARB and calcium channel blocker and/or diuretic; beta-blockers (β1-selective) may be used in selected patients with CAD or heart failure. 4

• Smoking cessation is mandatory 4