What are the current guidelines for managing hypertension in patients, including lifestyle modifications and medication?

New Hypertension Guidelines

Blood Pressure Targets

The current guideline-recommended blood pressure target is <130/80 mmHg for most adults under 65 years, with a systolic target of <130 mmHg for adults 65 years and older. 1

• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, the target remains <130/80 mmHg 1
• When initiating treatment for severe hypertension, the initial goal should be to reduce blood pressure by at least 20/10 mmHg 2, 1
• Target blood pressure should be achieved within 3 months of initiating or modifying therapy 1

Diagnosis and Confirmation

• Office blood pressure ≥140/90 mmHg defines hypertension, but must be confirmed with home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 1
• Use validated automated upper arm cuff devices with appropriate cuff size, measure blood pressure in both arms, and use the higher reading 1
• Assess for target organ damage, cardiovascular risk factors, diabetes, chronic kidney disease, and secondary causes of hypertension before initiating treatment 1

Lifestyle Modifications (First-Line for All Patients)

Lifestyle interventions are recommended for all patients with hypertension and can lower blood pressure by 10-20 mmHg. 2, 1

Dietary Changes

• Implement DASH or Mediterranean diet with 8-10 servings of fruits and vegetables daily, 2-3 servings of low-fat dairy products, and reduced saturated and trans fats 2, 1
• Reduce sodium intake to <1500 mg/day, or minimally reduce by at least 1000 mg/day 1
• Increase potassium intake to 3500-5000 mg/day through dietary sources 1
• Increase intake of vegetables high in nitrates (leafy vegetables, beetroot), and foods high in magnesium, calcium, and potassium (avocados, nuts, seeds, legumes, tofu) 2

Weight Management

• Target ideal body weight or minimum 1 kg reduction if overweight/obese 1
• Use ethnic-specific cut-offs for BMI and waist circumference, or alternatively maintain waist-to-height ratio <0.5 2

Physical Activity

• Perform at least 150 minutes of moderate-intensity aerobic exercise weekly 1
• Add resistance training 2-3 times per week 1

Alcohol and Smoking

• Limit alcohol to ≤2 standard drinks per day for men, ≤1 per day for women (10 g alcohol/standard drink), and avoid binge drinking 2, 1
• Complete smoking cessation with referral to cessation programs 2

Pharmacological Treatment

When to Initiate Medication

For Stage 1 hypertension (140-159/90-99 mmHg), start lifestyle modifications plus a single antihypertensive medication. 3

For Stage 2 hypertension (≥160/100 mmHg), immediately initiate two antihypertensive medications simultaneously (preferably as a single-pill combination) to achieve more rapid blood pressure control. 1, 3

First-Line Drug Selection

For non-Black patients, the preferred initial approach is two-drug combination therapy as a single-pill combination of low-dose ACE inhibitor or ARB plus dihydropyridine calcium channel blocker. 1

For Black patients, the preferred initial approach is low-dose ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide-like diuretic. 1

• First-line drug classes are thiazide or thiazide-like diuretics (hydrochlorothiazide or chlorthalidone), ACE inhibitors or ARBs (enalapril or candesartan), and calcium channel blockers (amlodipine) 4
• For patients with diabetes and albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), use ACE inhibitor or ARB as first-line treatment 1
• For patients with chronic kidney disease, use ACE inhibitor or ARB at maximum tolerated dose as first-line treatment, especially with albuminuria 1

Treatment Escalation Algorithm

If blood pressure remains uncontrolled on dual therapy, add a thiazide or thiazide-like diuretic as the third agent to achieve guideline-recommended triple therapy (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic). 1

• Chlorthalidone is preferred over hydrochlorothiazide due to its longer duration of action and superior cardiovascular outcomes 1
• If blood pressure remains uncontrolled after optimizing triple therapy, add spironolactone 25-50 mg daily as the preferred fourth-line agent for resistant hypertension 1

Monitoring and Follow-Up

• Schedule follow-up within 2-4 weeks initially to assess response and tolerability 1
• Once blood pressure is controlled, recheck every 3-6 months and encourage home blood pressure monitoring throughout treatment 1
• Check serum creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1

Critical Pitfalls to Avoid

Never combine two RAS blockers (ACE inhibitor + ARB) as this increases adverse events including hyperkalemia and acute kidney injury without additional cardiovascular benefit. 1

• Avoid clinical inertia: immediate combination therapy is more effective than sequential monotherapy titration for Stage 2 hypertension 1
• Do not discontinue lifestyle modifications once drug therapy starts—they are complementary and may reduce medication requirements 1
• Before adding medications for apparent resistant hypertension, verify medication adherence, identify interfering medications (especially NSAIDs), and screen for secondary causes including primary aldosteronism, obstructive sleep apnea, and renal artery stenosis 1
• Avoid beta-blockers as first-line therapy unless compelling indications exist (prior myocardial infarction, active angina, heart failure with reduced ejection fraction) 3