What are the current trends and updates in the management of essential hypertension?

Current Trends and Latest Updates in Essential Hypertension Management

The most significant shift in hypertension management is the adoption of lower blood pressure targets (<130/80 mmHg for most adults), fixed-dose combination therapy as first-line treatment, substitution of chlorthalidone for hydrochlorothiazide, and implementation of team-based care with telehealth monitoring—representing a fundamental departure from the previous 140/90 mmHg threshold and sequential monotherapy approach. 1, 2

Blood Pressure Targets: The Major Paradigm Shift

Target systolic BP of 120-129 mmHg for most adults if well tolerated, with a general target of <130/80 mmHg. 2, 3 This represents a dramatic change from the previous JNC-8 recommendations that allowed targets of <150/90 mmHg for adults ≥60 years. 1 The relaxation of BP goals in 2013-2014 directly correlated with a decline in hypertension control rates from 53.8% to 43.7% by 2017-2018, demonstrating the real-world harm of less aggressive targets. 1

Age-Specific Targets

• Adults <65 years: <130/80 mmHg 2, 3
• Adults ≥65 years: SBP <130 mmHg with individualized targets based on frailty 2, 3
• Adults ≥85 years: More lenient targets may be considered, but treatment should be maintained lifelong if well tolerated 2, 3

Pharmacological Treatment: New First-Line Strategies

Fixed-Dose Combinations as Initial Therapy

Use fixed-dose combinations as first-line therapy rather than sequential monotherapy. 1 This represents a major departure from traditional step-wise approaches and improves adherence while achieving BP control faster. 1

Thiazide Selection: Critical Update

Substitute long-acting chlorthalidone for hydrochlorothiazide, or alternatively use indapamide. 1 This specific recommendation reflects evidence that chlorthalidone provides superior cardiovascular outcomes compared to hydrochlorothiazide, despite both being classified as thiazide-type diuretics. 1

Calcium Channel Blocker Selection

Use long-acting amlodipine as the first-line calcium channel blocker. 1 This specificity in drug selection within class represents a refinement based on outcomes data. 1

First-Line Drug Classes

The three first-line drug classes remain: 2, 3, 4

• Thiazide/thiazide-like diuretics (preferably chlorthalidone or indapamide)
• ACE inhibitors or ARBs (never combine these two classes) 2, 3
• Calcium channel blockers (preferably amlodipine)

Beta-blockers are not first-line therapy for general hypertension unless specific indications exist (heart failure, post-MI, atrial fibrillation). 2, 3 This represents a clear demotion from previous guidelines where beta-blockers were considered equivalent first-line agents.

Blood Pressure Measurement: Enhanced Diagnostic Accuracy

Out-of-Office Monitoring Now Standard

Home blood pressure monitoring (HBPM) is the most practical method to document BP for medication titration towards achievement and maintenance of BP goal. 1 Ambulatory blood pressure monitoring (ABPM) is more sensitive for detecting masked hypertension. 1

Measure blood pressure in both arms at the first visit, use validated automated upper arm cuff devices, take two or more readings at each visit, and confirm diagnosis with home BP monitoring or 24-hour ambulatory monitoring. 2

Orthostatic Hypotension Assessment

Measure standing blood pressure in elderly patients and those with diabetes to detect orthostatic hypotension. 2, 3 Critically, asymptomatic orthostatic hypotension should not be a reason to withdraw or down-titrate treatment, as it is not associated with higher rates of CVD events, syncope, injurious falls, or acute renal failure. 1

Lifestyle Modifications: Quantified Benefits

Lifestyle modification continues as the cornerstone of therapy, with concurrent use of 2 or more interventions producing additive effects. 1 The specific BP reductions for each intervention are now quantified: 1

Weight Reduction

• Hypertension: -5 mmHg
• No hypertension: -3 mmHg 1

DASH Diet

• Hypertension: -11 mmHg
• No hypertension: -3 mmHg 1

Sodium Reduction

• Hypertension: -5 mmHg
• No hypertension: -2 mmHg 1

Aerobic Exercise

• Hypertension: -5 mmHg
• No hypertension: -3 mmHg 1

Alcohol Moderation

• Hypertension: -4 mmHg
• No hypertension: -3 mmHg 1

Secondary Hypertension Screening: Expanded Indications

All adults with difficult to control or resistant hypertension should be screened for primary aldosteronism. 1 This represents a major expansion from previous guidelines that reserved screening for more limited populations. If the aldosterone-to-renin ratio is low but plasma renin is low, consider 24-hour urine aldosterone measurement during salt loading conditions. 1

Autonomous aldosterone production may play a role in the pathogenesis of Stages 1 and 2 hypertension, not just resistant hypertension. 1

Treatment Intensity and Follow-Up: Aggressive Approach

Monthly visits until blood pressure target is achieved. 1 This represents more frequent monitoring than traditional quarterly visits and reflects the urgency of achieving control quickly.

Replace prescription of 30-day with 90-day refills when allowed. 1 This practical change improves adherence by reducing pharmacy visits.

Resistant Hypertension: Updated Definition

Resistant hypertension is defined as BP ≥130/80 mmHg in adults on ≥3 antihypertensive medications of different classes at maximum or maximally tolerated doses, or BP <130/80 mmHg requiring ≥4 drugs. 1 This definition uses the lower 130/80 mmHg threshold rather than the previous 140/90 mmHg cutoff. 1

Team-Based Care and Technology Integration

Use multidisciplinary team-based care to enhance lifestyle and medication adherence and solve social issues. 1 This includes: 1

• Telehealth strategies to augment office-based management
• Enhanced connectivity between patient, provider, and electronic health record
• Screening for social determinants of health
• Consideration of obstacles to care

Home BP self-monitoring and telemonitoring are effective in facilitating antihypertensive drug titration leading to achievement and maintenance of BP goal. 1

Special Populations: Young Adults

Young adults with hypertension have earlier onset of CVD events compared with those with normal BP, making it inappropriate to delay treatment. 1 The evidence supports initial management with lifestyle modification for 6-12 months followed by antihypertensive drug therapy if BP remains above goal in young adults with evidence of target organ damage. 1

Cognitive Benefits: New Evidence

For older adults with hypertension, intensive BP lowering may prevent or at least partially arrest cognitive decline. 1 This represents new evidence supporting aggressive treatment in elderly populations, countering previous concerns about over-treatment.

Key Differences from Previous Recommendations

What Changed:

1. BP targets lowered from 140/90 to 130/80 mmHg for most adults 1, 2
2. Fixed-dose combinations now preferred over sequential monotherapy 1
3. Chlorthalidone specifically recommended over hydrochlorothiazide 1
4. Monthly follow-up until goal achieved (not quarterly) 1
5. Home BP monitoring now standard for diagnosis and management 1
6. Orthostatic hypotension no longer a reason to reduce treatment intensity 1
7. Primary aldosteronism screening expanded to all difficult-to-control cases 1
8. Team-based care and telehealth formally integrated into management 1
9. Beta-blockers demoted from first-line status 2, 3
10. Cognitive benefits now recognized as treatment outcome in elderly 1

What Stayed the Same:

• First-line drug classes (thiazides, ACE-I/ARBs, CCBs) remain standard 2, 3, 4
• Lifestyle modification remains foundational 1, 5
• Never combine ACE inhibitors with ARBs 2, 3