What are the guidelines for managing hypertension (Htn) in an adult patient?

Hypertension Management Guidelines

Blood Pressure Targets

For most adults with hypertension, target blood pressure should be <130/80 mm Hg, with the most recent evidence supporting an even more aggressive systolic target of 120-129 mm Hg if well tolerated. 1

• Adults <65 years: Target BP <130/80 mm Hg 1, 2
• Adults ≥65 years (noninstitutionalized, ambulatory, community-dwelling): Target systolic BP <130 mm Hg 1, 2
• European guidelines (2024): Target systolic BP 120-129 mm Hg for most adults if treatment is well tolerated, representing the most aggressive contemporary recommendation 1
• WHO guidelines (2022): Target BP <140/90 mm Hg for patients without comorbidities (strong recommendation), but <130 mm Hg systolic for those with known CVD (strong recommendation) or high cardiovascular risk (conditional recommendation) 1

Special Population Targets

• Stable ischemic heart disease: BP <130/80 mm Hg 1
• Chronic kidney disease (stage 3 or higher): BP <130/80 mm Hg 1
• Diabetes mellitus: BP <130/80 mm Hg, though most diabetic patients can be assumed to have ≥10% 10-year ASCVD risk 1, 2
• Heart failure with preserved ejection fraction: Systolic BP <130 mm Hg after volume management 1
• Pregnancy (chronic or gestational hypertension): BP <140/90 mm Hg but not <80 mm Hg diastolic 1

Initial Pharmacologic Treatment

Initiate treatment with a two-drug combination as a single-pill formulation for most patients, preferably combining a RAS blocker with either a calcium channel blocker or thiazide-like diuretic. 2, 3

First-Line Drug Classes

The following four drug classes are recommended as first-line agents 1:

• Thiazide or thiazide-like diuretics (preferably chlorthalidone over hydrochlorothiazide) 1, 4
• ACE inhibitors 1, 4
• Angiotensin receptor blockers (ARBs) 1, 4
• Long-acting dihydropyridine calcium channel blockers 1, 4

Preferred Initial Combinations

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker 2, 3
• RAS blocker + thiazide/thiazide-like diuretic 2, 3
• Calcium channel blocker + thiazide/thiazide-like diuretic 2

Race-Specific Considerations

In Black patients, including those with diabetes, thiazide diuretics and calcium channel blockers are preferred as first-line agents, as beta blockers and RAS inhibitors are less effective at lowering BP in this population. 1, 2

Treatment Initiation Thresholds

Stage 2 Hypertension (BP ≥140/90 mm Hg)

Initiate pharmacologic treatment immediately with two-drug combination therapy, particularly when BP is >20/10 mm Hg above target. 1, 2

• Patients with BP ≥160/100 mm Hg require prompt treatment, careful monitoring, and rapid regimen adjustment until control is achieved 1

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

• With known CVD or 10-year ASCVD risk ≥10%: Initiate pharmacologic treatment 1
• Without elevated CVD risk: Lifestyle modifications for 3 months, then pharmacologic treatment if BP remains ≥130/80 mm Hg 1, 3
• Diabetes mellitus: Initiate treatment at BP ≥130/80 mm Hg 1

Elevated BP (120-129/<80 mm Hg)

• Low/medium CVD risk (<10% over 10 years): Lifestyle modifications only 1, 3
• High CVD risk: After 3 months of lifestyle intervention, initiate pharmacologic treatment if confirmed BP ≥130/80 mm Hg 1

Treatment Escalation Algorithm

Step 1: Two-Drug Combination

Start with RAS blocker + calcium channel blocker or RAS blocker + thiazide-like diuretic as single-pill combination 2, 3

Step 2: Three-Drug Combination

If BP remains uncontrolled, escalate to RAS blocker + dihydropyridine calcium channel blocker + thiazide-like diuretic, preferably as single-pill combination. 1, 2

Step 3: Four-Drug Regimen (Resistant Hypertension)

Add spironolactone 25-50 mg daily as the preferred fourth agent if serum potassium <4.5 mEq/L and eGFR >45 mL/min/1.73m². 5

Alternative fourth-line agents if spironolactone contraindicated 5:

• Eplerenone 50-200 mg daily (requires higher dosing than spironolactone)
• Amiloride
• Vasodilating beta-blockers (labetalol, carvedilol, nebivolol)
• Doxazosin or clonidine

Step 4: Fifth-Line and Beyond

• Hydralazine: Start 10 mg four times daily, increase to 25 mg four times daily after 2-4 days, then 50 mg four times daily for maintenance 5
• Minoxidil: Reserve as last resort due to poor tolerability 5

Specific Comorbidity Management

Stable Ischemic Heart Disease

Use guideline-directed medical therapy (GDMT) beta blockers, ACE inhibitors, or ARBs as first-line therapy, with addition of dihydropyridine calcium channel blockers for persistent angina. 1

• GDMT beta blockers include carvedilol, metoprolol succinate, nadolol, bisoprolol, propranolol, and timolol 1
• Avoid atenolol (less effective than placebo in reducing cardiovascular events) 1
• Avoid beta blockers with intrinsic sympathomimetic activity 1
• For angina with uncontrolled hypertension, add dihydropyridine calcium channel blockers to GDMT beta blockers 1

Chronic Kidney Disease

• Target BP <130/80 mm Hg 1
• Use ACE inhibitors for CKD stage 3 or higher, or stage 1-2 with albuminuria ≥300 mg/d 1
• Use ARBs if ACE inhibitors not tolerated 1
• Switch to loop diuretics if eGFR <30 mL/min/1.73m² 5

Diabetes Mellitus

• Target BP <130/80 mm Hg 1, 2
• For BP 130-139/80-89 mm Hg: Lifestyle therapy for maximum 3 months, then add pharmacologic treatment with RAS blockers 1
• For BP ≥140/90 mm Hg: Immediate drug therapy plus lifestyle modifications 1
• Multiple drug therapy (≥2 agents) generally required 1

Pregnancy

Transition to methyldopa, nifedipine, or labetalol during pregnancy; ACE inhibitors, ARBs, and direct renin inhibitors are contraindicated. 1

• Initiate treatment at confirmed office BP ≥140/90 mm Hg 1
• Target BP <140/90 mm Hg but not <80 mm Hg diastolic 1

Lifestyle Modifications

Weight loss is among the most effective lifestyle interventions for blood pressure control. 3, 4

• Sodium restriction: <2,300 mg/day, ideally <1,500 mg/day 3, 4
• Potassium supplementation: Increase dietary potassium intake 3, 4
• Physical activity: ≥150 minutes of moderate-intensity aerobic exercise per week 3, 4
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women 5, 4
• Healthy dietary pattern: DASH diet or similar 4

Follow-Up and Monitoring

Reassess monthly after initiating or adjusting therapy until BP control is achieved, then every 3-5 months for patients under control. 1, 2

• Use home BP monitoring to confirm diagnosis and guide treatment 1, 2, 3
• Obtain ambulatory BP monitoring to exclude white coat hypertension before initiating treatment 1, 2
• Implement team-based care with electronic health records and telehealth strategies 1, 3

Critical Pitfalls to Avoid

Never combine two RAS blockers (ACE inhibitor + ARB), as this increases risk without additional benefit. 1, 3

• Do not use monotherapy when BP is >20/10 mm Hg above target - initiate two-drug combination immediately 2
• Do not continue hydrochlorothiazide in resistant hypertension - switch to chlorthalidone or indapamide for superior efficacy 5
• Do not assume white coat effect without confirmation via home or ambulatory BP monitoring 2
• Do not abruptly discontinue beta blockers - taper to avoid rebound hypertension 5
• Do not combine non-dihydropyridine calcium channel blockers with beta blockers due to bradycardia and heart block risk 5
• Do not delay treatment in stage 2 hypertension - prompt dual-agent therapy is required 2

Resistant Hypertension Management

Confirm true resistance with 24-hour ambulatory BP monitoring (excludes white coat effect in ~50% of cases) and verify medication adherence before adding agents. 5

Optimization Steps Before Adding Fourth Agent

• Switch from hydrochlorothiazide to chlorthalidone 12.5-25 mg daily or indapamide 1.5-2.5 mg daily 5
• Use loop diuretics if eGFR <30 mL/min/1.73m² or volume overload present 5
• Discontinue interfering substances (NSAIDs, stimulants, oral contraceptives) 1, 5
• Screen for secondary causes: primary aldosteronism, obstructive sleep apnea, renal artery stenosis 5

Specialist Referral

Refer to hypertension specialist if BP remains uncontrolled after 6 months of optimized four-drug regimen. 1, 5