What are the current guidelines for managing hypertension in adults?

Current Guidelines for Managing Hypertension in Adults

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

Blood Pressure Classification and Treatment Initiation

The 2017 ACC/AHA guidelines fundamentally changed hypertension management by lowering diagnostic thresholds and treatment targets 3:

• Normal BP: <120/80 mm Hg - reassess annually 2
• Elevated BP: 120-129/<80 mm Hg - implement lifestyle modifications only, reassess in 3-6 months 3, 1, 2
• Stage 1 Hypertension: 130-139/80-89 mm Hg - calculate 10-year ASCVD risk:
  • If ASCVD risk <10%: lifestyle modifications alone, reassess in 3-6 months 2
  • If ASCVD risk ≥10%: initiate both lifestyle modifications and pharmacotherapy, reassess in 1 month 1, 2
• Stage 2 Hypertension: ≥140/90 mm Hg - immediately start dual-drug therapy plus lifestyle modifications, reassess in 1 month 2
• Very High BP: ≥180/110 mm Hg - prompt evaluation and treatment within 1 week 2

Blood Pressure Targets

Target BP <130/80 mm Hg for adults under 65 years. 3, 1, 2, 4

For adults 65 years and older, target systolic BP <130 mm Hg if ambulatory, community-dwelling, and non-institutionalized. 3, 1, 2 The guidelines emphasize careful titration and close monitoring in older adults with high comorbidity burden, using clinical judgment and team-based approaches 3.

Pharmacologic Treatment Algorithm

First-Line Therapy

Start with a two-drug single-pill combination preferably containing: 1, 2

• RAS blocker (ACE inhibitor or ARB) PLUS
• Dihydropyridine calcium channel blocker OR thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) 3, 1

For stage 1 hypertension with ASCVD risk ≥10%, monotherapy with one agent from thiazide-type diuretic, ACE inhibitor/ARB, or calcium channel blocker is acceptable 2.

Dose Titration for Lisinopril (Example ACE Inhibitor)

• Initial dose: 10 mg once daily 5
• Usual dosage range: 20-40 mg once daily 5
• Maximum studied dose: 80 mg daily (though doses above 40 mg show minimal additional benefit) 5
• With diuretics: Start at 5 mg once daily 5

Escalation Strategy

If BP remains above goal on dual therapy: Switch to triple-drug single-pill combination containing ACE inhibitor or ARB + calcium channel blocker + thiazide-like diuretic 1, 2

If BP still uncontrolled on triple therapy: Add spironolactone as the preferred fourth agent 1

Critical Medication Pitfall

Never combine two RAS blockers (ACE inhibitor plus ARB) - this is potentially harmful. 2

Lifestyle Modifications

All patients require lifestyle interventions, which have additive effects with pharmacotherapy 4:

• Weight loss: Most effective lifestyle intervention; achieve and maintain healthy BMI 1, 4
• Sodium restriction: <2,300 mg/day, ideally <1,500 mg/day 1, 4
• Potassium supplementation: Increase dietary potassium intake 1, 4
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly 1, 4
• Dietary pattern: DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy, low in red meat and added sugars) 1, 6, 7
• Alcohol moderation: Limit or eliminate alcohol consumption 4

The DASH diet combined with sodium reduction produces dose-dependent BP decreases and can be as effective as some antihypertensive medications 6, 7.

Diagnostic Confirmation

Before initiating treatment, confirm diagnosis with: 1, 2

• Accurate office BP measurements using proper technique 3
• Home BP monitoring or 24-hour ambulatory BP monitoring to exclude white coat hypertension 3, 1, 8
• Assessment for medication non-adherence 2
• Screening for secondary causes if resistant hypertension develops 3, 2

Screen for secondary hypertension in approximately 10% of cases where specific treatment of the underlying cause reduces cardiovascular risk 3.

Resistant Hypertension Management

Resistant hypertension is defined as BP ≥130/80 mm Hg despite adherence to three or more antihypertensive agents from different classes (including a diuretic), or requiring four or more medications 3.

Management approach: 3

• Confirm accurate BP measurements and exclude white coat effect
• Assess medication adherence
• Maximize diuretic therapy (switch to chlorthalidone or indapamide)
• Add mineralocorticoid receptor antagonist (spironolactone or eplerenone)
• Discontinue interfering substances (NSAIDs, stimulants, oral contraceptives)
• Exclude secondary causes
• Refer to hypertension specialist if uncontrolled

Team-Based Care and Adherence Strategies

Implement multidisciplinary team-based care utilizing: 1, 2

• Electronic health records and patient registries 3, 1
• Telehealth strategies 3, 1, 2
• Community health workers for resource-constrained populations 1
• Once-daily dosing and single-pill combination products 3, 2
• Motivational interviewing and goal-setting 1, 2

Up to 25% of patients don't fill initial prescriptions, and only 1 in 5 achieve sufficient adherence for trial-level benefits 3.

Special Populations

Older adults (≥65 years): Target systolic BP <130 mm Hg if tolerated, avoiding diastolic BP <65 mm Hg in those >80 years 3

Patients with coarctation of aorta: Strict BP control is critical due to increased risk of hypertension and premature coronary artery disease 3

Perioperative management: Continue chronic beta blockers and most antihypertensives; consider holding ACE inhibitors/ARBs perioperatively; never abruptly discontinue beta blockers or clonidine 3

Evidence for Cardiovascular Benefit

Each 10 mm Hg reduction in systolic BP decreases cardiovascular events by approximately 20-30% 4. The benefit is mediated primarily by BP reduction itself rather than specific drug properties, with the largest consistent benefit being stroke risk reduction 3, 5. Despite proven benefits, only 44% of US adults with hypertension achieve BP control to even <140/90 mm Hg 4.