What are the recommended treatment guidelines for a general adult population with primary hypertension?

Hypertension Treatment Guidelines for Adults

Blood Pressure Classification and Treatment Initiation

For adults with primary hypertension, initiate pharmacological treatment at BP ≥130/80 mm Hg if 10-year ASCVD risk is ≥10%, or at BP ≥140/90 mm Hg regardless of cardiovascular risk, targeting <130/80 mm Hg in adults under 65 years and systolic <130 mm Hg in those 65 and older. 1, 2

BP Categories and Treatment Approach:

• Elevated BP (120-129/<80 mm Hg): Implement lifestyle modifications only; reassess in 3-6 months if 10-year ASCVD risk <10% 2, 3

• Stage 1 Hypertension (130-139/80-89 mm Hg):

  • Calculate 10-year ASCVD risk 3
  • If ASCVD risk <10%: lifestyle modifications alone, reassess in 3-6 months 3
  • If ASCVD risk ≥10%: initiate both lifestyle modifications and pharmacotherapy immediately 2, 3

• Stage 2 Hypertension (≥140/90 mm Hg): Start combination therapy with lifestyle modifications plus two antihypertensive drugs from different classes; reassess in 1 month 3

• Very High BP (≥180/110 mm Hg): Prompt evaluation and treatment initiation within 1 week 3

The 2017 ACC/AHA guideline represents a shift from the previous JNC 7 threshold of 140/90 mm Hg, resulting in only a modest increase in patients requiring medication but significantly expanding the population diagnosed with hypertension. 1

Pharmacological Treatment Algorithm

First-Line Medication Classes:

Start with thiazide or thiazide-like diuretics, ACE inhibitors or ARBs, or long-acting dihydropyridine calcium channel blockers as first-line agents. 1, 4, 5

Specific Medication Approach:

• Initial Monotherapy (Stage 1 HTN with ASCVD risk ≥10%): Choose one agent from thiazide-type diuretic, ACE inhibitor/ARB, or calcium channel blocker 3

• Initial Dual Therapy (Stage 2 HTN): Start with two-drug combination, preferably as single-pill combination, consisting of RAS blocker (ACE inhibitor or ARB) plus either dihydropyridine calcium channel blocker or thiazide-like diuretic 2, 3

• Triple Therapy (if BP remains above goal): Switch to single-pill combination of ACE inhibitor or ARB + calcium channel blocker + thiazide-like diuretic 2, 3

• Resistant Hypertension (fourth agent): Add spironolactone as the preferred fourth agent; consider maximizing diuretic therapy by switching to chlorthalidone or indapamide instead of hydrochlorothiazide 1, 2

Critical Pitfall: Never combine two RAS blockers (ACE inhibitor plus ARB) as this can be potentially harmful. 2

Blood Pressure Targets

Target BP <130/80 mm Hg for adults under 65 years; for adults 65 and older who are ambulatory, community-dwelling, and non-institutionalized, target systolic BP <130 mm Hg if tolerated. 1, 2, 3

The WHO guideline maintains a more conservative target of <140/90 mm Hg for most adults, though the ACC/AHA guideline provides stronger evidence from trials like SPRINT supporting the lower target. 1 For older adults with high comorbidity burden and limited life expectancy, clinical judgment and team-based assessment of risk-benefit tradeoffs should guide treatment intensity. 1

Lifestyle Modifications (Foundation of All Treatment)

All patients should implement comprehensive lifestyle changes including: weight loss to achieve healthy BMI, sodium restriction to <2,300 mg/day (ideally <1,500 mg/day), DASH dietary pattern with 8-10 servings of fruits/vegetables daily, potassium intake of 3,500-5,000 mg/day through diet, at least 150 minutes of moderate-intensity aerobic exercise weekly, and alcohol limitation to ≤2 drinks/day for men and ≤1 drink/day for women. 2, 4, 5

Weight loss is among the most effective lifestyle interventions, with an SBP reduction of 10 mm Hg decreasing CVD event risk by approximately 20-30%. 2, 5 These modifications are partially additive and enhance pharmacologic therapy efficacy. 5

Additional recommendations include:

• Complete tobacco cessation with referral to cessation programs 4
• Elimination of sugar-sweetened beverages 4
• 2-3 servings of low-fat dairy products daily 4

Diagnostic Confirmation and Monitoring

Before initiating treatment, confirm diagnosis with accurate office BP measurements using proper technique, and obtain home BP monitoring or 24-hour ambulatory BP monitoring to exclude white coat hypertension. 2, 3

The prevalence estimates from NHANES likely overestimate hypertension because they rely on single-visit measurements rather than the guideline-recommended average of ≥2 readings on ≥2 occasions. 1

Follow-Up Schedule:

• Normal BP: reassess annually 3
• Elevated BP or Stage 1 HTN (low risk): reassess in 3-6 months 3
• Stage 1 HTN (high risk) or Stage 2 HTN: reassess in 1 month 3
• Monitor renal function and potassium at least annually when using ACE inhibitors, ARBs, or diuretics 4

Achieve target BP within 3 months of initiating or intensifying therapy. 4

Resistant Hypertension Management

Resistant hypertension is defined as BP ≥130/80 mm Hg despite adherence to three or more antihypertensive agents from different classes at optimal doses, including a diuretic, or requiring four or more medications. 1 The prevalence is estimated at approximately 17% using the new definition (13% with the previous 140/90 mm Hg threshold). 1

Management steps:

1. Verify accurate office BP measurements and obtain home/ambulatory readings to exclude white coat effect 1
2. Assess medication adherence (up to 25% of patients don't fill initial prescriptions) 1
3. Identify and discontinue interfering substances (NSAIDs, stimulants, oral contraceptives) 1
4. Screen for secondary causes of hypertension 1, 3
5. Maximize diuretic therapy by switching to chlorthalidone or indapamide 1
6. Add mineralocorticoid receptor antagonist (spironolactone or eplerenone) 1
7. Refer to hypertension specialist if BP remains uncontrolled 1

Strategies to Improve Treatment Adherence

Implement team-based care utilizing multidisciplinary approaches, prescribe once-daily dosing with single-pill combination products, employ motivational interviewing and goal-setting strategies, and use electronic health records, patient registries, and telehealth strategies. 1, 2, 3

Only 1 in 5 patients has sufficiently high adherence to achieve benefits observed in randomized trials. 1 Once-daily dosing and combination pills significantly improve adherence. 1 Community health workers can be particularly effective in resource-constrained populations. 2

Despite proven benefits, only 44% of U.S. adults with hypertension have their BP controlled to <140/90 mm Hg, with rates declining from 54% in 2013-2014 to <44% in 2017-2018. 1, 5 Control rates are consistently higher in women than men, whites than blacks and Hispanics, and those of higher socioeconomic status. 1