What is the recommended protocol for diagnosing and treating hypertension in adults, including blood pressure targets, lifestyle modifications, first‑line pharmacologic therapy, titration schedule, and management of hypertensive emergencies?

Blood Pressure Protocol for Adults

Blood Pressure Classification and Diagnosis

Hypertension is now defined as systolic BP ≥130 mmHg or diastolic BP ≥80 mmHg, with stage 1 hypertension at 130-139/80-89 mmHg and stage 2 at ≥140/90 mmHg. 1

BP Categories:

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

Diagnostic Confirmation:

• Base diagnosis on an average of ≥2 readings obtained on ≥2 separate occasions 1
• Confirm with out-of-office monitoring (ambulatory or home BP monitoring) to detect white coat hypertension (high office BP but normal out-of-office) or masked hypertension (normal office BP but high out-of-office) 1
• Measure BP at every routine visit with proper technique: seated position, feet on floor, arm supported at heart level, after 5 minutes of rest 1

Blood Pressure Targets

Target BP <130/80 mmHg for adults <65 years with CVD or high cardiovascular risk; <140/90 mmHg for all others without comorbidities. 2, 3

Specific Targets:

• Adults <65 years: <130/80 mmHg 2, 3
• Adults ≥65 years: SBP <130 mmHg 3
• Patients with diabetes or CKD: <130/80 mmHg 1
• Patients with known CVD: SBP <130 mmHg (strong recommendation) 2
• General population without comorbidities: <140/90 mmHg 2

Lifestyle Modifications

All patients with BP >120/80 mmHg require lifestyle interventions before or concurrent with pharmacologic therapy. 1, 3

Essential Components:

• Weight loss to achieve BMI 18.5-24.9 kg/m² 3
• Dietary sodium restriction to 1200-2300 mg/day 3
• Increased dietary potassium intake 3
• DASH dietary pattern (rich in fruits, vegetables, low-fat dairy, reduced saturated fats) 1, 3
• Physical activity: 150 minutes moderate-intensity or 90 minutes vigorous aerobic exercise weekly 3
• Alcohol moderation: ≤14 units/week for men, ≤9 units/week for women 3
• Smoking cessation 3

Pharmacologic Therapy Initiation

For stage 2 hypertension (≥140/90 mmHg or >20/10 mmHg above goal), initiate with two-drug combination therapy from different first-line classes, preferably as a single-pill combination. 2

Treatment Initiation Strategy:

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

• Start with lifestyle modifications for up to 3 months if no CVD, diabetes, or CKD 1
• Initiate pharmacologic therapy immediately if patient has established CVD, diabetes, CKD, or 10-year ASCVD risk ≥10% 1
• Begin with single-agent monotherapy and titrate as needed 2

Stage 2 Hypertension (≥140/90 mmHg):

• Initiate pharmacologic therapy immediately along with lifestyle modifications 1, 2
• Start with two-drug combination from different first-line classes 2
• Use single-pill combination products to improve adherence 2

First-Line Pharmacologic Agents

Thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, and long-acting dihydropyridine calcium channel blockers are equally effective first-line agents. 2

Drug Class Selection:

General Population:

• Thiazide-type diuretics (chlorthalidone preferred over hydrochlorothiazide based on outcomes data) 1, 2, 3
• ACE inhibitors (e.g., enalapril, lisinopril) 2, 3
• ARBs (e.g., losartán, candesartan) - lowest discontinuation rates due to adverse effects 2, 3
• Long-acting calcium channel blockers (e.g., amlodipine) 2, 3

Special Populations:

• Black adults without heart failure or CKD: Thiazide diuretic or calcium channel blocker 2
• Patients with diabetes, CKD, or proteinuria: ACE inhibitor or ARB as initial agent 1, 2
• Patients with heart failure or post-MI: ACE inhibitor/ARB plus beta-blocker 1

Agents to Avoid as First-Line:

• Beta-blockers should not be first-line unless ischemic heart disease or heart failure is present (less effective for stroke prevention) 2
• Alpha-blockers and central alpha-agonists produce more adverse effects and are not recommended first-line 2

Titration and Combination Therapy

Most patients require multiple agents for adequate BP control; typical effective combination is diuretic + ACE inhibitor or ARB + calcium channel blocker. 2

Escalation Algorithm:

Step 1 (Monotherapy):

• Single first-line agent at standard dose 2

Step 2 (Two-Drug Combination):

• Add second agent from different first-line class with complementary mechanism 2
• Preferred combinations: ACE inhibitor or ARB + calcium channel blocker OR ACE inhibitor or ARB + thiazide diuretic 2

Step 3 (Three-Drug Combination):

• Add third first-line agent: ACE inhibitor or ARB + calcium channel blocker + thiazide diuretic 2
• Ensure diuretic is included and at maximal dose 1

Step 4 (Resistant Hypertension):

• Add spironolactone (mineralocorticoid receptor antagonist) as fourth agent 4, 5
• Refer to hypertension specialist if BP remains uncontrolled on three drugs including a diuretic 4

Monitoring Schedule

Follow up monthly after initiating or changing medications until target BP is achieved, then every 3-5 months once at goal. 2

Monitoring Protocol:

• Monthly visits until BP target achieved 2
• Every 3-5 months once BP controlled 2
• Monitor renal function and potassium within first 3 months when using ACE inhibitors, ARBs, or diuretics 1, 2
• Home BP monitoring to detect white coat effect or masked uncontrolled hypertension 1

Management of Hypertensive Emergencies

Hypertensive emergency (BP >180/120 mmHg with acute end-organ damage) requires immediate BP reduction within hours using IV titratable agents in an ICU setting. 6

Classification:

Hypertensive Emergency:

• Definition: SBP >180 mmHg or DBP >120 mmHg WITH acute end-organ damage (cardiac, renal, neurologic injury) 6
• Management: Admit to ICU for immediate BP reduction with short-acting IV antihypertensive 6
• Goal: Reduce BP within hours (not to normal immediately—gradual reduction to avoid ischemia) 6

Hypertensive Urgency:

• Definition: SBP >180 mmHg or DBP >120 mmHg WITHOUT acute end-organ damage 6
• Management: Oral antihypertensives as outpatient with close follow-up 6
• Goal: Reduce BP within days 4, 6

Preferred IV Agents for Emergencies:

• Labetalol (beta-blocker with alpha-blocking activity) 6
• Nicardipine (calcium channel blocker) 6
• Fenoldopam (dopamine agonist) 6
• Esmolol (ultra-short-acting beta-blocker) 6
• Clevidipine (ultra-short-acting calcium channel blocker) 6

Agents to AVOID:

• Immediate-release nifedipine (unpredictable, excessive BP drops) 6
• Hydralazine (unpredictable response) 6
• Sodium nitroprusside (use with extreme caution due to cyanide/thiocyanate toxicity) 6

Common Pitfalls

• Do not use immediate-release nifedipine for hypertensive urgencies—causes unpredictable precipitous BP drops 6
• Do not reduce BP too rapidly in hypertensive emergencies—risk of cerebral, cardiac, or renal ischemia 6
• Do not diagnose hypertension on single office reading—confirm with repeat measurements and out-of-office monitoring 1
• Do not forget to monitor electrolytes and renal function when using RAAS inhibitors or diuretics 1
• Do not use beta-blockers as first-line unless specific indication (heart failure, post-MI, ischemic heart disease) 2