What are the Indian guidelines for managing systemic hypertension in adults?

Management of Systemic Hypertension: Indian Guidelines

For Indian patients with hypertension, initiate treatment with combination therapy using an ARB plus calcium channel blocker as first-line pharmacotherapy, alongside aggressive salt restriction to <5g/day, given the markedly elevated stroke risk and salt sensitivity characteristic of South Asian populations. 1, 2

Diagnosis and Blood Pressure Thresholds

Diagnostic Confirmation:

• Hypertension is diagnosed when office BP ≥140/90 mmHg, confirmed by out-of-office measurements using home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 3, 1
• For screening BP 140-159/90-99 mmHg, confirm diagnosis with home or ambulatory monitoring within 1 month 3
• When BP ≥160/100 mmHg, exclude hypertensive emergency immediately and confirm diagnosis as soon as possible 3

Critical Pitfall: Morning and nighttime hypertension patterns are significantly more prevalent in Asian populations compared to Europeans, making home BP monitoring particularly important for accurate diagnosis 1

Lifestyle Modifications (First-Line for All Patients)

Dietary Interventions:

• Salt restriction to <5g/day (approximately 2g sodium/day) is mandatory - this is more aggressive than general recommendations due to marked salt sensitivity in Indian populations 3, 1, 4
• Increase potassium intake to 3500-5000 mg/day through fresh fruits and vegetables (avoid in chronic kidney disease or with potassium-sparing diuretics) 1
• Adopt Mediterranean or DASH diet patterns emphasizing vegetables, fruits, whole grains, and nuts while reducing trans fats 3, 2
• Limit free sugar consumption to <10% of energy intake and discourage sugar-sweetened beverages 3

Physical Activity:

• Exercise is more beneficial than dietary modulation alone in Indian patients - initiate 50-60 minutes of moderate-intensity aerobic exercise 3-4 times weekly, or alternatively 150 minutes/week of moderate exercise or 75 minutes/week of vigorous exercise 2, 3
• Complement with low- or moderate-intensity resistance training 2-3 times weekly 3

Weight and Alcohol Management:

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women), with approximately 1 mmHg systolic BP reduction per 1 kg weight loss 3, 1
• Limit alcohol to <100g/week of pure alcohol (≤2 standard drinks/day for men, ≤1 for women), though complete avoidance is preferred 3, 1

Tobacco Cessation:

• Mandatory smoking cessation with referral to cessation programs, as tobacco independently causes cardiovascular disease and mortality 3

Pharmacological Treatment Algorithm

First-Line Therapy:

• Initiate combination therapy immediately for most patients with confirmed hypertension (BP ≥140/90 mmHg) - monotherapy results in poor BP control rates 1, 5
• Preferred combination: ARB plus dihydropyridine calcium channel blocker as single-pill combination 1, 2
• ARBs are superior to ACE inhibitors in diabetic hypertensive patients and avoid the 3-fold higher angioedema risk of ACE inhibitors 3, 2
• Among calcium channel blockers, novel molecules like cilnidipine provide better cardiovascular and renal protection in diabetic patients 2

Dose Escalation Strategy:

1. Start with low-dose ARB, increase to full dose if needed 1
2. Add calcium channel blocker if BP not controlled 1
3. Add thiazide-like diuretic (chlorthalidone or indapamide preferred over thiazides) as three-drug combination, preferably as single-pill combination 3, 5
4. Add spironolactone as fourth-line agent for resistant hypertension 5

Critical Pitfall: Never combine two RAS blockers (ACE inhibitor plus ARB) - this is potentially harmful 5, 3

Alternative First-Line Options:

• Thiazide-like diuretic plus calcium channel blocker 3
• Thiazide-like diuretic plus ARB 3

Beta-Blockers:

• Not recommended as first-line therapy 6
• Reserve for compelling indications: angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control 3
• Avoid in combination with diuretics in diabetic patients due to increased cardiovascular events and hyperglycemia risk 2

Blood Pressure Targets

Standard Targets:

• Target BP <140/90 mmHg for all patients 1
• Consider <130/80 mmHg in high cardiovascular risk patients based on tolerability 1
• Target ≤130/80 mmHg for patients with diabetes, renal impairment, or established cardiovascular disease 1

Special Populations:

• Adults ≥65 years: target systolic BP <130 mmHg 5
• Adults >80 years: initiate treatment only when office systolic BP ≥160 mmHg 3
• Pregnant women with chronic or gestational hypertension: lower BP below 140/90 mmHg but not below 80 mmHg diastolic 3

Critical Consideration: A 10 mmHg increase in systolic BP increases hemorrhagic stroke risk by 72% in Asians versus 49% in Australians/New Zealanders - lowering diastolic BP by just 3 mmHg could decrease stroke incidence by approximately one-third in Asia-Pacific populations 1

Monitoring Strategy

Home Blood Pressure Monitoring:

• Strongly recommended for all Asian patients given higher prevalence of morning and nighttime hypertension 1
• Use validated BP measuring devices with appropriate cuff size 3
• Confirm diagnosis using home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 1

Follow-Up Schedule:

• Monthly follow-up for dose titration until BP controlled 1
• After hypertensive emergency, monthly follow-up until target BP and regression of hypertension-mediated organ damage achieved 3

Baseline Investigations:

• Serum creatinine, eGFR, and urine albumin-creatinine ratio (repeat annually if moderate-to-severe CKD) 3
• 12-lead ECG for all patients; echocardiography if ECG abnormalities or cardiac symptoms 3
• Fundoscopy if BP >180/110 mmHg or in diabetic patients 3
• Screen for secondary hypertension in adults diagnosed before age 40 (except obese young adults - start with obstructive sleep apnea evaluation) 3

Special Considerations for South Asian Populations

Ethnic-Specific Risks:

• South Asians have particularly high risk for coronary artery disease and type 2 diabetes 3, 1
• Stroke risk (particularly hemorrhagic stroke) is substantially greater than Western populations 1
• Non-ischemic heart failure occurs at higher rates 1
• Salt sensitivity is markedly increased, often accompanied by mild obesity 3, 1

Medication Timing:

• Take medications at the most convenient time to establish habitual pattern and improve adherence 3
• Maintain BP-lowering treatment lifelong, even beyond age 85 years, if well tolerated 3

Team-Based Care Approach

• Utilize multidisciplinary team-based care with electronic health records and telehealth strategies 5
• Employ community health workers, particularly for resource-constrained populations 5
• Implement motivational interviewing, goal setting, self-monitoring, and feedback to improve adherence 5
• The WHO HEARTS Technical Package provides free modules on team-based care relevant for low-resource settings 3