What are the guidelines for managing systemic hypertension in adults, particularly those with underlying kidney disease or diabetes?

Management of Systemic Hypertension in Adults

All adults with hypertension should be treated to a blood pressure goal of <130/80 mmHg, with lifestyle modifications as foundational therapy and pharmacologic treatment initiated based on BP stage and cardiovascular risk. 1

Blood Pressure Classification and Diagnosis

The 2017 ACC/AHA guidelines redefined hypertension thresholds 1:

• Normal BP: <120/80 mmHg 1
• Elevated BP: 120-129/<80 mmHg 1
• Stage 1 Hypertension: 130-139/80-89 mmHg 1
• Stage 2 Hypertension: ≥140/90 mmHg 1

Confirm the diagnosis using out-of-office BP measurements (home BP monitoring or ambulatory BP monitoring) to exclude white coat hypertension before initiating treatment. 1 White coat hypertension transitions to sustained hypertension in 1-5% of patients annually, so recheck these patients yearly. 1

Screening for Secondary Hypertension

Screen for secondary causes of hypertension in approximately 10% of cases where specific treatment can reduce cardiovascular risk. 1 Screen when patients present with resistant hypertension, sudden onset or worsening of hypertension, age <30 years without risk factors, or clinical features suggesting specific secondary causes. 1

Lifestyle Modifications (First-Line for All Patients)

Implement the following evidence-based lifestyle interventions for all patients with elevated BP or hypertension 1:

• Sodium restriction: <1500 mg/day, or at minimum reduce by 1000 mg/day 1
• Potassium supplementation: 3500-5000 mg/day 1
• Weight loss: Target ideal body weight or minimum 1 kg reduction if overweight/obese (reduces BP by 5-20 mmHg per 10 kg lost) 1, 2
• DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy with reduced saturated and total fat (reduces BP by 8-14 mmHg) 1, 2
• Physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise, or 3 sessions/week of isometric resistance training (reduces BP by 4-9 mmHg) 1, 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women (reduces BP by 2-4 mmHg) 1, 2

The DASH diet may be the single most effective lifestyle intervention for BP reduction. 3 These interventions have additive effects when combined and enhance the efficacy of pharmacologic therapy. 2

Pharmacologic Treatment Thresholds

Stage 1 Hypertension (130-139/80-89 mmHg)

Initiate drug therapy immediately if the patient has 1:

• Clinical cardiovascular disease (CVD), OR
• 10-year ASCVD risk ≥10% (using ACC/AHA Pooled Cohort Equations), OR
• Diabetes mellitus (automatically high-risk), OR
• Chronic kidney disease (automatically high-risk) 1

For patients with 10-year ASCVD risk <10% and no CVD, diabetes, or CKD, use lifestyle modifications alone for 3-6 months before considering drug therapy. 1 The BP threshold for drug treatment in this lower-risk group is 140/90 mmHg. 1

Stage 2 Hypertension (≥140/90 mmHg)

Initiate combination pharmacologic therapy with two antihypertensive agents from different classes immediately, along with lifestyle modifications. 1 Patients with BP ≥160/100 mmHg should be treated promptly and monitored carefully with upward dose adjustments as necessary. 1

First-Line Antihypertensive Medications

For most adults without compelling indications, initiate therapy with thiazide or thiazide-like diuretics, calcium channel blockers (CCBs), ACE inhibitors (ACEIs), or angiotensin receptor blockers (ARBs). 1, 2

Thiazide diuretics (especially chlorthalidone) and CCBs are preferred as first-line therapy in most U.S. adults due to superior efficacy. 1 Chlorthalidone is preferred over hydrochlorothiazide based on its prolonged half-life and proven CVD risk reduction in trials. 1

Medication Selection for Black Patients

For Black patients (including those with diabetes), use thiazide diuretics or CCBs as first-line agents, as beta-blockers and renin-angiotensin system inhibitors are less effective at lowering BP in this population. 1

Special Populations

Chronic Kidney Disease

All patients with CKD and hypertension should be treated to a BP goal of <130/80 mmHg. 1, 4

Use an ACE inhibitor as first-line therapy for all CKD patients with hypertension 1, 4:

• CKD stage 3 or higher (regardless of albuminuria) 1, 4
• CKD stage 1-2 with albuminuria ≥300 mg/day or ≥300 mg/g creatinine 1, 4

If ACE inhibitor is not tolerated, substitute an ARB. 1, 4 Administer at the highest approved tolerated dose for maximum renoprotective benefit. 4

Monitor serum creatinine and potassium 2-4 weeks after initiating or increasing ACE inhibitor/ARB dose. 1, 4 Continue therapy unless creatinine rises >30% within 4 weeks. 4

Never combine an ACE inhibitor, ARB, and direct renin inhibitor together—this increases adverse events without additional benefit. 4

For second-line therapy when BP goal is not met, add either a long-acting dihydropyridine CCB or thiazide-type diuretic. 4 For third-line, add the other class not yet used. 4

Post-Kidney Transplant

Use a calcium channel blocker as first-line therapy for kidney transplant recipients, as this improves GFR and kidney graft survival. 1, 4 Target BP <130/80 mmHg, but in the first month post-transplant, target <160/90 mmHg to avoid hypotension-induced graft thrombosis. 1

Diabetes Mellitus

Initiate antihypertensive drug therapy at BP ≥130/80 mmHg in adults with diabetes, with a treatment goal of <130/80 mmHg. 1

Use an ACE inhibitor or ARB if albuminuria is present. 1 If no albuminuria, consider usual first-line drug choices (thiazide diuretics, CCBs, ACEIs, or ARBs). 1

Older Adults (≥65 Years)

Treat older adults to the same BP target of <130/80 mmHg as younger patients, provided treatment is well tolerated. 1, 4 Both the HYVET and SPRINT trials demonstrated substantial benefit and safety of intensive BP lowering in older adults, including those who were frail but living independently. 1

Initiate therapy cautiously, especially when using two drugs, and monitor carefully for adverse effects including orthostatic hypotension. 1 BP-lowering therapy is one of few interventions proven to reduce mortality risk in frail older adults. 1

Treatment Goals

The target BP for all adults with hypertension after initiating drug therapy is <130/80 mmHg, regardless of ASCVD risk. 1 This represents a more aggressive target than older guidelines (which recommended <140/90 mmHg), reflecting evidence from SPRINT and other trials showing benefit from tighter control. 1, 4

An SBP reduction of 10 mmHg decreases CVD event risk by approximately 20-30%. 2

Monitoring and Follow-Up

Follow-up schedule based on BP category 1:

• Normal BP (<120/80 mmHg): Recheck annually 1
• Elevated BP (120-129/<80 mmHg): Recheck every 3-6 months 1
• Stage 1 hypertension not qualifying for drug therapy: Follow-up every 3-6 months 1
• Patients initiating drug therapy: Follow approximately monthly for drug titration until BP is controlled 1

After initiating drug therapy, evaluate adherence and therapeutic response monthly until control is achieved. 1 Interventions such as home BP monitoring, team-based care, and telehealth improve BP control rates. 1

Resistant Hypertension

If BP remains uncontrolled on three or more antihypertensive agents (including a diuretic), reassess for 1:

• Medication non-adherence
• White coat effect
• Secondary causes of hypertension
• Inadequate diuretic dosing (a common pitfall leading to fluid retention and poor BP control) 4

Critical Contraindications

ACE inhibitors and ARBs are absolutely contraindicated during pregnancy. 4 Use caution in patients with peripheral vascular disease due to association with renovascular disease. 4

Common Pitfalls to Avoid

• Inadequate diuretic dosing leads to fluid retention and poor BP control, while excessive dosing causes volume contraction, hypotension, and worsening renal function 4
• Do not discontinue antihypertensive medications simply because BP falls below target if the patient tolerates the regimen without adverse effects—continue the effective therapy 4
• Avoid atenolol as it is less effective than placebo in reducing cardiovascular events 1
• Do not use beta blockers with intrinsic sympathomimetic activity 1