What are the latest guidelines for managing hypertension in adults, including lifestyle modifications and pharmacological therapy?

Latest Guidelines for Hypertension Management in Adults

Blood Pressure Targets

For most adults with hypertension, target a systolic blood pressure of 120-129 mmHg, provided treatment is well tolerated. 1 If this target cannot be achieved due to poor tolerance, aim for systolic BP "as low as reasonably achievable" using the ALARA principle. 1

• For adults under 65 years: target <130/80 mmHg 1, 2
• For adults 65 years and older: target systolic <130 mmHg 1, 2
• For pregnant women with chronic or gestational hypertension: lower BP below 140/90 mmHg but not below 80 mmHg diastolic 1

Pharmacological Treatment Initiation

Start combination therapy with two drugs as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg), preferably as a single-pill combination. 1, 2 The preferred combination is a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic. 1, 2

Exceptions to Combination Therapy:

• Patients aged ≥85 years 1
• Symptomatic orthostatic hypotension 1
• Moderate-to-severe frailty 1
• Elevated BP (120-139/70-89 mmHg) with concomitant indication for treatment 1

Specific Populations:

Black adults without heart failure or CKD: Initiate with thiazide-type diuretic or calcium channel blocker as first-line therapy. 1 Two or more medications are typically required to achieve BP control in this population. 1

Pregnant women: Transition to methyldopa, nifedipine, or labetalol. 1 Never use ACE inhibitors, ARBs, or direct renin inhibitors in pregnancy. 1

Young adults diagnosed before age 40: Perform comprehensive screening for secondary hypertension causes, except in obese young adults where obstructive sleep apnea evaluation should be prioritized first. 1

Medication Escalation Algorithm

1. If BP not controlled on two-drug combination: Escalate to three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic), preferably as single-pill combination 1, 2

2. If BP remains uncontrolled on three drugs: Add spironolactone (mineralocorticoid receptor antagonist) as the preferred fourth agent 1, 2

3. Critical contraindication: Never combine two RAS blockers (ACE inhibitor + ARB) together 1, 2

Lifestyle Modifications (First-Line for All Patients)

All hypertensive patients should receive intensive lifestyle counseling regardless of medication status. 1 These interventions have additive BP-lowering effects when combined. 1

Specific Recommendations:

• Diet: DASH diet (American guidelines) 1 or Mediterranean diet (European guidelines) 1
• Sodium restriction: <2,300 mg/day, ideally <1,500 mg/day 2
• Potassium supplementation: Increase dietary potassium intake 1, 2
• Weight loss: Achieve and maintain healthy BMI; most effective single lifestyle intervention 2, 3
• Physical activity: Minimum 150 minutes of moderate-intensity aerobic exercise weekly 2
• Alcohol moderation: Maximum 14 drinks/week for men, 9 drinks/week for women 1
• Smoking cessation: For CVD prevention 1

Timing for Elevated BP (120-139/<80 mmHg):

For adults with elevated BP and low/medium CVD risk (<10% over 10 years): implement lifestyle modifications for 3 months before considering pharmacological treatment. 1 If BP remains ≥130/80 mmHg after 3 months and CVD risk is sufficiently high, initiate drug therapy. 1

Diagnostic Confirmation Requirements

Before initiating treatment, confirm hypertension diagnosis with out-of-office BP measurements. 1, 2 Use home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) to exclude white coat hypertension. 1, 2 ABPM is more sensitive for detecting masked hypertension. 1

Follow-Up and Monitoring

• Reassess BP within 2-4 weeks after initiating or changing medications 4
• Achieve target BP within 3 months of treatment initiation 4
• Monthly visits until BP target achieved 1
• Assess orthostatic hypotension at every visit by measuring BP in sitting and standing positions 4
• Use HBPM as the most practical method for medication titration 1

Medication Timing and Adherence

Patients should take medications at the most convenient time of day to establish habitual patterns and improve adherence. 1 There is no evidence supporting specific timing (morning vs. evening) for superior outcomes. 1

Prescribe 90-day refills instead of 30-day when allowed to improve adherence. 1

Team-Based Care Implementation

Utilize multidisciplinary team-based care with electronic health records and telehealth strategies. 1, 2 This approach is the most effective method for achieving BP control. 1 Implement motivational interviewing, goal setting, self-monitoring, and feedback mechanisms. 2

Resistant Hypertension

Definition: BP ≥130/80 mmHg on ≥3 antihypertensive medications at maximum tolerated doses (including a diuretic), or BP <130/80 mmHg requiring ≥4 medications. 1

Evaluation steps:

1. Exclude pseudoresistance (inaccurate measurement, white coat effect, nonadherence) 1
2. Screen for secondary causes, particularly primary aldosteronism in all patients with difficult-to-control or resistant hypertension 1
3. Maximize diuretic therapy; use loop diuretics in CKD patients 1
4. Add mineralocorticoid receptor antagonist (spironolactone) 1
5. Refer to hypertension specialist if uncontrolled after 6 months 1

Renal Denervation

Renal denervation is NOT recommended as first-line BP-lowering intervention due to lack of adequately powered outcomes trials demonstrating CVD benefits. 1 It is also not recommended for patients with eGFR <40 mL/min/1.73 m² or secondary hypertension. 1

Lifelong Treatment

Maintain BP-lowering drug treatment lifelong, even beyond age 85 years, if well tolerated. 1 For older adults (≥65 years) with high comorbidity burden and limited life expectancy, use clinical judgment and team-based approach for treatment intensity decisions. 1