What are the recent guidelines for managing hypertension in a general adult population?

Management of Hypertension: Current Guidelines

Blood Pressure Classification and Diagnosis

Use the 2017 ACC/AHA classification system which defines hypertension as BP ≥130/80 mm Hg, representing the most current evidence-based threshold for cardiovascular risk reduction. 1

The classification system includes:

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

Confirm diagnosis using out-of-office BP measurements (home monitoring or 24-hour ambulatory monitoring) with an average of ≥2 readings on ≥2 separate occasions before initiating treatment. 1 This prevents overdiagnosis from white coat effect and ensures accurate treatment decisions. 1

When to Initiate Pharmacological Treatment

Start antihypertensive medication immediately for Stage 2 Hypertension (≥140/90 mm Hg) combined with lifestyle modifications. 2, 3

For Stage 1 Hypertension (130-139/80-89 mm Hg), initiate pharmacotherapy only if the patient has:

• ASCVD risk ≥10% using the pooled cohort equation 2
• Established cardiovascular disease 1
• Diabetes mellitus 1
• Chronic kidney disease 1

For patients with Stage 1 Hypertension and ASCVD risk <10%, implement lifestyle modifications alone and reassess in 3-6 months. 2

First-Line Pharmacological Treatment

The European Society of Cardiology recommends initiating upfront combination therapy with two first-line antihypertensive agents as single-pill combinations for most patients with confirmed hypertension. 2 This represents the most current evidence (2026) and improves adherence compared to separate pills. 2

The three first-line drug classes are:

• Thiazide or thiazide-like diuretics (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1, 4
• ACE inhibitors or ARBs (such as enalapril or candesartan) 4
• Long-acting dihydropyridine calcium channel blockers (such as amlodipine) 2, 4

Start with low-dose combination therapy using two agents from different classes. 2 For Stage 2 Hypertension, a two-drug combination is recommended for most patients from the outset. 1

Beta-blockers are NOT first-line therapy for uncomplicated hypertension but should be reserved for specific indications including heart failure, post-myocardial infarction, or angina pectoris. 1, 3

Blood Pressure Targets

Target BP <130/80 mm Hg for adults <65 years of age. 1, 2

For adults ≥65 years who are ambulatory and community-dwelling, target systolic BP <130 mm Hg if tolerated. 1, 2

The European Society of Cardiology suggests a more aggressive systolic BP target of 120-129 mm Hg for most adults if well tolerated. 2, 3 This represents the most recent guideline recommendation (2026) and reflects evidence from intensive BP lowering trials. 2

Lifestyle Modifications (Essential for All Patients)

Implement the following evidence-based lifestyle interventions immediately, either before or alongside pharmacotherapy: 3, 4

• Weight reduction: Achieve and maintain BMI 18.5-24.9 kg/m² 2, 5
• DASH or Mediterranean dietary pattern 2, 4
• Sodium restriction: <2,300 mg/day (ideally <1,500 mg/day for greater effect) 2, 4
• Potassium supplementation: 3,500-5,000 mg/day through diet 2
• Regular aerobic exercise: 150 minutes/week of moderate-intensity activity 2, 5
• Alcohol limitation: Maximum 2 standard drinks/day for men, 1 for women 4, 5
• Smoking cessation 3

These interventions are partially additive and enhance the efficacy of pharmacological therapy. 4 An SBP reduction of 10 mm Hg through lifestyle modifications or medications decreases CVD events by approximately 20-30%. 4

Treatment Titration and Follow-Up Schedule

Reassess BP 1 month after initiating pharmacotherapy for Stage 1 Hypertension with high ASCVD risk or Stage 2 Hypertension. 2

If BP remains uncontrolled at 1 month, add a third agent from a different class (typically the missing component from the ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic combination). 1

Once BP is controlled, monitor every 3-6 months with annual assessment of renal function and potassium when using ACE inhibitors, ARBs, or diuretics. 2

Resistant Hypertension Management

Define resistant hypertension as BP ≥130/80 mm Hg despite adherence to three optimally dosed antihypertensive agents from different classes, including a diuretic. 2

Management algorithm for resistant hypertension:

1. Confirm true resistance by ruling out white coat effect with out-of-office BP monitoring 1
2. Maximize diuretic therapy by switching from hydrochlorothiazide to chlorthalidone or indapamide 1
3. Add spironolactone (mineralocorticoid receptor antagonist) as the fourth agent 1, 2
4. Use loop diuretics instead of thiazides in patients with CKD (eGFR <30 mL/min/1.73m²) 1
5. Refer to hypertension specialist if BP remains uncontrolled 1, 3

Strategies to Improve Adherence

Use single-pill combinations whenever possible to reduce pill burden and improve adherence. 1, 2

Implement team-based care involving pharmacists, nurses, and community health workers for BP monitoring and medication management. 1

Prescribe once-daily dosing at the most convenient time to establish habitual patterns. 1, 3

Utilize home BP monitoring with patient registries and electronic health records to track control rates. 1

Critical Pitfalls to Avoid

Never combine ACE inhibitors with ARBs due to increased adverse effects (hyperkalemia, acute kidney injury) without additional cardiovascular benefit. 1, 3

Do not use beta-blockers as first-line monotherapy for uncomplicated hypertension in patients without specific indications. 1, 3

Avoid relying solely on office BP measurements for diagnosis—always confirm with out-of-office monitoring to prevent misdiagnosis from white coat hypertension. 1, 3

Do not discontinue medications in elderly patients (even >85 years) if well tolerated, as treatment should be maintained lifelong. 3

Check for orthostatic hypotension in elderly patients and those with diabetes by measuring standing BP to avoid excessive BP lowering. 3