Current Hypertension Guidelines for Adults

Blood Pressure Classification and Diagnosis

Hypertension is now defined as blood pressure ≥130/80 mm Hg, with stage 1 hypertension at 130-139/80-89 mm Hg and stage 2 at ≥140/90 mm Hg. 1

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

The 2017 ACC/AHA guidelines lowered the diagnostic threshold from the previous 140/90 mm Hg cutoff, which increases the prevalence of hypertension in U.S. adults from 32% to 46%. 1 This change is based on robust evidence from the SPRINT trial showing that intensive blood pressure lowering to <130 mm Hg reduces cardiovascular morbidity and mortality by >25%. 2

Important caveat: The WHO 2022 guidelines maintain the traditional 140/90 mm Hg threshold for diagnosis, creating international divergence. 1 However, the ACC/AHA approach prioritizes earlier intervention to prevent cardiovascular events.

Blood Pressure Targets

For adults with confirmed hypertension and known CVD or 10-year ASCVD risk ≥10%, target BP <130/80 mm Hg (strong recommendation). 1

Target BP by Population:

General population <65 years: <130/80 mm Hg 1, 3
Adults ≥65 years (noninstitutionalized, ambulatory): SBP <130 mm Hg 1
Patients with diabetes or CKD: <130/80 mm Hg 1
Patients with stable ischemic heart disease: <130/80 mm Hg 1
All patients without comorbidities (WHO guideline): <140/90 mm Hg 1

Critical safety consideration: Avoid lowering diastolic BP below 60-70 mm Hg in high-risk patients, particularly those with coronary artery disease, as this may increase cardiovascular events. 4 The optimal diastolic range appears to be 70-79 mm Hg. 4

Lifestyle Modifications (First-Line for All)

All patients with elevated BP or hypertension should implement lifestyle modifications, which can reduce SBP by 4-11 mm Hg and enhance medication efficacy. 5

Evidence-Based Lifestyle Interventions:

Weight loss: Target BMI <25 kg/m² (reduces SBP ~5-20 mm Hg per 10 kg lost) 5
Sodium restriction: <2,300 mg/day, ideally <1,500 mg/day (reduces SBP ~5-6 mm Hg) 5
DASH dietary pattern: High in fruits, vegetables, whole grains, low-fat dairy, low in saturated fat (reduces SBP ~11 mm Hg) 5
Potassium supplementation: 3,500-5,000 mg/day through diet (reduces SBP ~4-5 mm Hg) 5
Physical activity: ≥150 minutes/week of moderate-to-vigorous aerobic exercise (reduces SBP ~5-8 mm Hg) 4, 5
Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women (reduces SBP ~4 mm Hg) 4, 5

These interventions have partially additive effects and should be implemented concurrently. 5

First-Line Pharmacologic Therapy

Four drug classes are recommended as first-line therapy: thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, and long-acting dihydropyridine calcium channel blockers (strong recommendation, high-quality evidence). 1, 3

Monotherapy vs. Combination Therapy:

Stage 1 hypertension (130-139/80-89 mm Hg): Start with single-agent monotherapy and titrate upward 1, 3
Stage 2 hypertension (≥140/90 mm Hg or >20/10 mm Hg above goal): Initiate two-drug combination therapy immediately, preferably as single-pill combination 1, 3

Rationale for combination therapy in Stage 2: Two submaximal doses from different classes produce larger BP reductions with fewer side effects than maximal doses of a single agent. 6 Single-pill combinations improve adherence and persistence. 1

Preferred First-Line Agents by Population:

General population (non-black): Any of the four first-line classes 1, 3
Black patients without HF or CKD: Thiazide diuretic or calcium channel blocker (ACE inhibitors/ARBs less effective for stroke prevention) 1, 4, 7
Diabetes mellitus: ACE inhibitor or ARB preferred 1, 4
CKD (stage 3+ or albuminuria ≥300 mg/day): ACE inhibitor or ARB 1, 4
Post-MI or stable ischemic heart disease: Beta blocker + ACE inhibitor or ARB 1
Heart failure with reduced ejection fraction: ACE inhibitor or ARB + beta blocker + diuretic 1

Common pitfall: Beta-blockers should NOT be used as first-line therapy in uncomplicated hypertension, especially in patients >60 years, as they are less effective than other agents for stroke prevention and cardiovascular outcomes. 3 They are reserved for compelling indications (post-MI, HFrEF, stable angina). 1

Typical Effective Combinations:

Two-drug regimen: Thiazide diuretic + (ACE inhibitor or ARB) OR Calcium channel blocker + (ACE inhibitor or ARB) 1, 3
Three-drug regimen: Thiazide diuretic + (ACE inhibitor or ARB) + Calcium channel blocker 4, 3

Never combine: ACE inhibitor + ARB + direct renin inhibitor (increases adverse effects without benefit) 1, 6

Monitoring and Follow-Up

After initiating or adjusting antihypertensive therapy, follow up monthly until BP target is achieved, then every 3-5 months once controlled. 1, 3

Monitoring Schedule:

Initial phase: Monthly visits until BP at goal 1, 3
Maintenance phase: Every 3-5 months once stable 1, 3
Dose adjustments: Allow ≥4 weeks between changes to observe full BP response 6

Laboratory Monitoring:

Baseline: Serum creatinine, eGFR, potassium, fasting glucose, lipid panel 1
With ACE inhibitors/ARBs/diuretics: Recheck creatinine, eGFR, and potassium within 1-2 weeks of initiation, with each dose increase, and annually thereafter 6
Acceptable creatinine increase: Up to 50% above baseline or to 3 mg/dL (whichever is greater) 6

Out-of-office BP monitoring (home or ambulatory) is essential to assess treatment response, detect white coat effect, and identify masked uncontrolled hypertension. 1

Special Population Considerations

Pregnancy:

Women with hypertension who become pregnant must be transitioned to methyldopa, nifedipine, or labetalol. 1

Absolutely contraindicated in pregnancy: ACE inhibitors, ARBs, direct renin inhibitors (fetal toxicity) 1, 6

Older Adults (≥65 years):

Treatment with SBP goal <130 mm Hg is recommended for noninstitutionalized, ambulatory community-dwelling older adults with average SBP ≥130 mm Hg. 1

Thiazide diuretics (particularly chlorthalidone) are preferred for preventing heart failure in this population 4, 3
Use caution with initial combination therapy in those at risk for orthostatic hypotension 1
For older adults with high comorbidity burden and limited life expectancy, clinical judgment and team-based assessment of risk/benefit is reasonable 1

Chronic Kidney Disease:

ACE inhibitors or ARBs are first-line to improve kidney outcomes. 1, 4

Target BP <130/80 mm Hg 1
Monitor creatinine and potassium closely 6

Diabetes Mellitus:

Target BP <130/80 mm Hg with ACE inhibitor or ARB as preferred initial agent. 1, 4

Black Patients:

Initial therapy should be thiazide diuretic or calcium channel blocker unless HF or CKD is present. 4, 7

ACE inhibitors/ARBs are less effective as monotherapy in this population 4, 7
Black patients have higher risk of angioedema with ACE inhibitors 6

Resistant Hypertension

Resistant hypertension is defined as BP ≥130/80 mm Hg despite ≥3 antihypertensive medications at optimal doses (including a diuretic), or BP <130/80 mm Hg requiring ≥4 medications. 1

Systematic Approach:

Confirm true resistance: Exclude white coat effect with home/ambulatory BP monitoring; assess medication adherence 1
Identify contributing factors: Obesity, physical inactivity, excessive alcohol, high sodium intake, NSAIDs, sympathomimetics, oral contraceptives 1
Screen for secondary causes: Primary aldosteronism (elevated aldosterone/renin ratio), CKD (eGFR <60), renal artery stenosis, pheochromocytoma, obstructive sleep apnea 1
Optimize diuretic therapy: Use loop diuretics in CKD patients 1
Add mineralocorticoid receptor antagonist (spironolactone) 1
Refer to hypertension specialist if uncontrolled after 6 months 1

Critical Pitfalls to Avoid

Delaying combination therapy in Stage 2 hypertension (≥140/90 mm Hg) 4, 3
Using beta-blockers as first-line in patients >60 years without compelling indication 3
Excessive DBP lowering below 60 mm Hg in high-risk patients 4
Prescribing alpha-blockers or central alpha-agonists as first-line (higher adverse effects, especially in elderly) 3
Combining ACE inhibitor + ARB 1, 6
Continuing ACE inhibitors/ARBs in pregnancy 1, 6
Ignoring out-of-office BP monitoring to detect white coat or masked hypertension 1

What are the current hypertension guidelines for diagnosis, blood pressure targets, lifestyle modifications, first‑line pharmacologic therapy, and special population considerations in adults?

Help us tailor your experience