What are the current guidelines for diagnosing and managing hypertension in adults, including blood pressure targets, lifestyle modifications, first‑line pharmacologic therapy, and treatment of resistant hypertension?

Guidelines for Managing Hypertension in Adults

Blood Pressure Classification and Diagnosis

Hypertension is diagnosed when blood pressure is ≥140/90 mm Hg according to the 2024 European Society of Cardiology (ESC) guidelines, while the 2017 ACC/AHA guidelines use a lower threshold of ≥130/80 mm Hg. 1, 2 This international divergence creates practical challenges, but for clinical decision-making, the ESC's more conservative 140/90 mm Hg threshold reduces overdiagnosis while the ACC/AHA approach identifies more at-risk patients earlier. 2

Key diagnostic categories:

• Normal BP: <120/70 mm Hg 1
• Elevated BP: 120-139/70-89 mm Hg 1
• Stage 1 Hypertension (ACC/AHA): 130-139/80-89 mm Hg 2
• Stage 2 Hypertension: ≥140/90 mm Hg 1, 2

Confirmation requires out-of-office monitoring (home or ambulatory BP) to exclude white-coat hypertension and ensure accurate diagnosis. 2, 3 Measure BP at every routine visit using proper technique: patient seated with feet flat, arm supported at heart level, after 5 minutes of rest, with appropriate cuff size. 3

Blood Pressure Treatment Targets

For most adults with hypertension, the target BP is 120-129/70-79 mm Hg according to the 2024 ESC guidelines. 1 This represents a shift toward more intensive control compared to older targets.

Specific targets by population:

• Adults <65 years with CVD or 10-year ASCVD risk ≥10%: <130/80 mm Hg 1, 2
• Adults ≥65 years (ambulatory, non-institutionalized): Systolic <130 mm Hg 1, 2
• Diabetes mellitus or chronic kidney disease: <130/80 mm Hg 1, 2
• Stable ischemic heart disease: <130/80 mm Hg 2

Critical caveat: Avoid lowering diastolic BP below 60-70 mm Hg in high-risk patients, as excessive diastolic reduction may increase adverse cardiovascular events; optimal diastolic range is 70-79 mm Hg. 2

Exercise caution in specific populations where treatment should be deferred until BP >140/90 mm Hg: 1

• Pre-treatment symptomatic orthostatic hypotension
• Age ≥85 years
• Moderate-to-severe frailty
• Limited life expectancy (<3 years)
• eGFR <30 mL/min/1.73 m²

Lifestyle Modifications (First-Line for All)

All patients with BP ≥120/70 mm Hg should implement lifestyle measures before or alongside pharmacotherapy. 1, 4

Evidence-based interventions include: 4

• Weight loss in overweight/obese patients
• Dietary sodium restriction and potassium supplementation
• DASH dietary pattern (high in fruits, vegetables, low-fat dairy)
• Regular physical activity (150 minutes/week moderate-intensity aerobic exercise)
• Alcohol moderation or elimination

These interventions are partially additive and enhance the efficacy of pharmacologic therapy. 4

When to Initiate Pharmacologic Therapy

For elevated BP (120-139/70-89 mm Hg): 1

• Initiate lifestyle measures for 3 months
• Add pharmacotherapy if BP remains ≥130/80 mm Hg AND patient has:
  • 10-year CVD risk ≥10%, OR
  • High-risk conditions (established CVD, diabetes, CKD, familial hypercholesterolemia, hypertension-mediated organ damage), OR
  • 10-year CVD risk 5-10% PLUS risk modifiers or abnormal risk tool tests

For hypertension (≥140/90 mm Hg): 1

• Initiate lifestyle measures AND pharmacotherapy simultaneously
• Do not delay treatment beyond 3 months to avoid therapeutic inertia

First-Line Pharmacologic Therapy

Four drug classes are first-line agents: thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, and long-acting dihydropyridine calcium-channel blockers (CCBs). 2, 4 All produce similar BP reductions: approximately 9/5 mm Hg with office BP and 5/3 mm Hg with ambulatory monitoring as monotherapy. 1

Initial Drug Selection Strategy

Stage 1 hypertension (130-139/80-89 mm Hg): Start single-agent therapy and titrate upward. 2

Stage 2 hypertension (≥140/90 mm Hg or >20/10 mm Hg above goal): Begin with two-drug combination, preferably as a single-pill formulation. 2 Combination therapy using two submaximal doses from different classes yields larger BP reductions with fewer adverse effects than maximal dosing of a single agent. 2

Population-Specific First-Line Choices

General (non-Black) adult population: Any of the four first-line classes may be selected. 2

Black patients without heart failure or CKD: Thiazide diuretics (especially chlorthalidone) or CCBs are preferred because renin-angiotensin system inhibitors are less effective at lowering BP in this population. 1, 2

Diabetes mellitus: ACE inhibitor or ARB is preferred. 2, 3

CKD (stage 3+ or albuminuria ≥300 mg/day): ACE inhibitor or ARB is first-line. 2

Post-myocardial infarction or stable ischemic heart disease: Combine β-blocker with ACE inhibitor or ARB. 2

Heart failure with reduced ejection fraction: Combine ACE inhibitor or ARB, β-blocker, and diuretic. 2

Recommended Two-Drug Combinations

Preferred regimens: 2

• Thiazide diuretic + (ACE inhibitor or ARB)
• CCB + (ACE inhibitor or ARB)

Avoid combining ACE inhibitor + ARB + direct renin inhibitor due to increased adverse effects without added benefit. 2

β-Blockers: Not First-Line in Uncomplicated Hypertension

β-Blockers should not be used as first-line therapy in uncomplicated hypertension, especially in patients >60 years, because they are less effective for stroke prevention. 2 Reserve β-blockers for compelling indications (post-MI, heart failure, ischemic heart disease). 2

Monitoring and Follow-Up

After initiating or adjusting therapy, review patients monthly until BP target is achieved, then every 3-5 months for maintenance. 2 Space dose adjustments at least 4 weeks apart to allow full BP response. 2

Baseline laboratory evaluation: 2

• Serum creatinine and eGFR
• Potassium
• Fasting glucose or HbA1c
• Lipid panel
• Urinalysis with albumin-to-creatinine ratio
• 12-lead ECG 3

When prescribing ACE inhibitors, ARBs, or diuretics, repeat creatinine, eGFR, and potassium within 1-2 weeks of initiation, after each dose increase, and annually thereafter. 2 An increase in serum creatinine up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable. 2

Out-of-office BP monitoring (home or ambulatory) is essential to assess treatment response, detect white-coat effect, and identify masked uncontrolled hypertension. 2

Resistant Hypertension

Resistant hypertension is defined as BP ≥130/80 mm Hg despite adherence to ≥3 antihypertensive agents at optimal doses (including a diuretic), or BP <130/80 mm Hg requiring ≥4 agents. 2, 3

Systematic Approach to Resistant Hypertension

Step 1: Confirm true resistance 2, 5

• Exclude white-coat effect with out-of-office monitoring
• Assess medication adherence (pill counts, pharmacy refill records)
• Ensure proper BP measurement technique

Step 2: Identify contributing lifestyle factors 2, 5

• Obesity
• Excess alcohol intake
• High sodium intake
• NSAIDs or other interfering substances (decongestants, stimulants, oral contraceptives)

Step 3: Screen for secondary causes 2, 5, 6

• Primary aldosteronism (most common)
• Chronic kidney disease
• Renal artery stenosis
• Pheochromocytoma/paraganglioma
• Obstructive sleep apnea
• Cushing's syndrome
• Coarctation of the aorta (especially in young adults)

Step 4: Optimize diuretic therapy 2, 5

• Use loop diuretics in CKD (eGFR <30 mL/min/1.73 m²)
• Ensure adequate diuretic dosing

Step 5: Add mineralocorticoid-receptor antagonist (e.g., spironolactone) 2, 5

• Effective as fourth-line agent even without biochemical evidence of aldosterone excess

Step 6: Refer to hypertension specialist if uncontrolled after 6 months 2

Special Populations

Pregnancy

Women who become pregnant while on antihypertensive therapy must immediately discontinue ACE inhibitors, ARBs, and direct renin inhibitors due to fetal toxicity. 2, 7, 3 Switch to methyldopa, nifedipine, or labetalol. 2, 3

Older Adults (≥65 Years)

Non-institutionalized, ambulatory adults ≥65 years with systolic BP ≥130 mm Hg should be treated to systolic target <130 mm Hg. 2, 7 However, exercise caution when initiating combination therapy in older adults at risk for orthostatic hypotension. 2

For older adults with high comorbidity burden, limited life expectancy, or frailty, use individualized clinical judgment and team-based risk-benefit assessment. 2, 7 Consider deferring treatment until BP >140/90 mm Hg in these patients. 1

Common Pitfalls to Avoid

Delaying combination therapy in stage 2 hypertension (≥140/90 mm Hg) increases cardiovascular risk; start two drugs immediately. 2

Using β-blockers as first-line agents in patients >60 years without compelling indication leads to inferior stroke prevention. 2

Excessive diastolic lowering below 60 mm Hg in high-risk patients may increase adverse cardiovascular events. 2, 8

Combining ACE inhibitor with ARB (or adding direct renin inhibitor) should be avoided due to lack of benefit and higher adverse-event risk. 2

Failing to employ out-of-office BP monitoring can miss white-coat or masked hypertension, compromising management. 2

Continuing ACE inhibitors or ARBs during pregnancy is absolutely contraindicated. 2