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

Standard Hypertension Treatment Guidelines for Adults

Blood Pressure Classification and Diagnosis

Hypertension is defined as blood pressure ≥130/80 mm Hg, and diagnosis requires confirmation with proper measurement technique using validated devices, with readings obtained on at least two separate occasions. 1

• Accurate BP measurement requires the patient to sit quietly for >5 minutes with feet flat on the floor, back supported, arm at heart level, using the correct cuff size that encircles 80% of the arm, with no talking during measurement 1
• Consider out-of-office BP monitoring (home or ambulatory) to exclude white coat hypertension before initiating treatment 1, 2
• BP classification: Elevated (120-129/<80 mm Hg), Stage 1 (130-139/80-89 mm Hg), Stage 2 (≥140/90 mm Hg) 1

Initial Patient Evaluation

All newly diagnosed hypertensive patients require basic laboratory testing including fasting glucose, complete blood count, lipid profile, serum creatinine with eGFR, electrolytes (sodium, potassium, calcium), TSH, urinalysis, and electrocardiogram. 1

• Screen for secondary causes by assessing for BP lability with episodic symptoms (pheochromocytoma), snoring/hypersomnolence (sleep apnea), muscle cramps/weakness (hyperaldosteronism), medication use (NSAIDs, cocaine, amphetamines), and absence of family history 1
• Optional testing includes echocardiogram, uric acid, and urinary albumin-to-creatinine ratio to assess target organ damage 1

Lifestyle Modifications (First-Line for All Patients)

All patients with BP >120/80 mm Hg should implement lifestyle modifications, which are partially additive to pharmacological therapy and can reduce BP by amounts comparable to single-drug therapy. 3, 4

Specific Lifestyle Interventions:

• Weight management: Achieve and maintain BMI 18.5-24.9 kg/m²; weight loss is among the most effective lifestyle interventions 3, 5, 4
• Dietary sodium restriction: Limit intake to <2,300 mg/day, ideally <1,500 mg/day 3, 2, 4
• DASH diet: Adopt dietary pattern high in fruits, vegetables, low-fat dairy products, whole grains, and low in saturated fat 1, 5, 6
• Potassium supplementation: Increase dietary potassium to 3,500-5,000 mg/day unless contraindicated 3, 5, 4
• Physical activity: Engage in at least 150 minutes of moderate-intensity aerobic exercise per week 3, 5, 2, 4
• Alcohol moderation: Limit to ≤2 standard drinks/day for men (maximum 14/week), ≤1 drink/day for women (maximum 9/week) 3, 6, 4
• Smoking cessation: Mandatory for all patients who smoke 3

Pharmacological Treatment Initiation Thresholds

Initiate pharmacological therapy immediately (combined with lifestyle modifications) for patients with BP ≥140/90 mm Hg, or BP ≥130/80 mm Hg in high-risk patients with established CVD, diabetes, CKD, or 10-year ASCVD risk ≥10%. 1, 3, 4

• For Stage 1 hypertension (130-139/80-89 mm Hg) with low cardiovascular risk (<10% 10-year ASCVD risk), attempt lifestyle modifications alone for 3-6 months before initiating medication 3, 5, 6
• For Stage 2 hypertension (≥140/90 mm Hg), initiate two antihypertensive medications from different classes immediately plus lifestyle modifications 3, 5, 2

First-Line Pharmacological Therapy

The four first-line medication classes are thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, and long-acting dihydropyridine calcium channel blockers—all equally effective at reducing cardiovascular morbidity and mortality. 3, 4

Medication Selection Algorithm:

For most patients without compelling indications, initiate treatment with a two-drug combination (preferably as single-pill combination) consisting of a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide-like diuretic. 3, 5, 2

Special Population Considerations:

• Black patients: Calcium channel blockers or thiazide diuretics are more effective than ACE inhibitors or ARBs as monotherapy 3, 2
• Patients with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB is mandatory first-line choice because these agents reduce proteinuria and slow kidney disease progression beyond BP reduction alone 3, 2
• Patients with coronary artery disease: ACE inhibitor or ARB should be selected as first-line therapy 3
• Patients with chronic kidney disease: RAS inhibitors (ACE inhibitors or ARBs) are first-line drugs because they reduce albuminuria and slow CKD progression 3
• Patients with diabetes: ACE inhibitor or ARB preferred, especially if albuminuria present 3, 7, 8

Blood Pressure Targets

Target BP <130/80 mm Hg for most adults <65 years; target systolic BP <130 mm Hg for adults ≥65 years if tolerated. 3, 5, 2, 4

• For adults ≥60 years without high-risk conditions, target SBP <150 mm Hg is acceptable (strong recommendation, high-quality evidence) 1
• For adults ≥60 years with history of stroke/TIA or high cardiovascular risk, consider target SBP <140 mm Hg 1

Medication Titration and Intensification

If BP remains above goal on initial two-drug combination, switch to single-pill combination of ACE inhibitor or ARB plus calcium channel blocker plus thiazide-like diuretic. 2

• If BP still remains above goal on three-drug combination, add spironolactone as the preferred fourth agent 2
• Titrate medications every 2-4 weeks until BP target achieved, with goal of reaching target within 3 months 3

Critical Monitoring Requirements

Monitor serum creatinine and potassium within 7-14 days after initiating or titrating ACE inhibitors, ARBs, or diuretics, then at least annually. 3, 2

• Accept creatinine increases up to 30% from baseline after RAS blocker initiation—this reflects beneficial reduction in intraglomerular pressure 3
• Discontinue or reduce RAS blocker dose if potassium >5.5 mEq/L or creatinine increases >30% 3

Follow-Up Schedule

Reassess BP 7-14 days after medication initiation or dose changes; once stable, follow-up every 3-6 months for patients at goal, monthly for those not at goal. 3, 5

Critical Pitfalls to Avoid

Never combine ACE inhibitors with ARBs—this increases adverse effects (hyperkalemia, acute kidney injury) without additional cardiovascular or renal benefit. 3, 2

• ACE inhibitors and ARBs are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential not using reliable contraception 3
• Avoid abrupt discontinuation of antihypertensive medications, which can cause rebound hypertension 4
• Do not rely on single office BP measurements for diagnosis—confirm with multiple readings on separate occasions 1

Strategies to Improve Adherence

Use single-pill combination medications when multiple drugs are needed, implement team-based care with pharmacists and nurses, and utilize home BP monitoring with telehealth follow-up. 5, 2

• Prescribe 90-day refills instead of 30-day when allowed 3
• Employ motivational interviewing and goal-setting strategies to improve patient engagement 5, 2