What is the recommended approach to manage hypertension in adults, including blood pressure target, lifestyle modifications, first‑line medication choices based on comorbidities, and follow‑up monitoring?

Management of Hypertension in Adults

Blood Pressure Targets

For most adults with hypertension, target blood pressure should be <130/80 mm Hg, with community-dwelling adults ≥65 years also treated to systolic <130 mm Hg. 1, 2

• Adults with confirmed hypertension and known cardiovascular disease or 10-year ASCVD risk ≥10% should achieve <130/80 mm Hg 2
• Non-institutionalized, ambulatory adults ≥65 years with average systolic ≥130 mm Hg should target systolic <130 mm Hg 1, 2
• Patients with diabetes mellitus or chronic kidney disease require <130/80 mm Hg 1, 2
• Critical caveat: Avoid lowering diastolic pressure below 60-70 mm Hg in high-risk patients, as excessive reduction increases adverse cardiovascular events 2
• For older adults (≥65 years) with high comorbidity burden and limited life expectancy, use clinical judgment and team-based assessment rather than aggressive targets 1

Lifestyle Modifications

All patients with blood pressure ≥120/70 mm Hg should implement lifestyle measures before or alongside pharmacologic therapy. 2

• Weight loss to achieve BMI <25 kg/m² 3
• Dietary sodium restriction to <2.3 g/day (ideally <1.5 g/day) with potassium supplementation 3
• DASH dietary pattern emphasizing fruits, vegetables, whole grains, and low-fat dairy 3
• Regular aerobic physical activity (150 minutes/week moderate intensity) 3
• Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) or elimination 3
• These interventions are partially additive and enhance pharmacologic efficacy 3

First-Line Medication Selection

Four drug classes constitute first-line therapy: thiazide/thiazide-like diuretics (especially chlorthalidone), ACE inhibitors, ARBs, and long-acting dihydropyridine calcium channel blockers. 1, 2, 3

General Adult Population (Non-Black, No Compelling Indications)

• Thiazide-like diuretics (chlorthalidone preferred) offer the strongest cardiovascular outcome evidence 1, 2
• Any of the four first-line classes may be initiated, but chlorthalidone demonstrates superior heart failure prevention versus calcium channel blockers and superior stroke prevention versus ACE inhibitors 2

Black Patients Without Heart Failure or CKD

• Initiate with thiazide diuretic or calcium channel blocker 1, 2
• ACE inhibitors and ARBs are less effective for stroke and heart failure prevention in this population 1, 2
• ARBs may be preferred over ACE inhibitors if renin-angiotensin system blockade is needed, due to lower rates of cough and angioedema 2
• Black patients have greater angioedema risk with ACE inhibitors 4

Diabetes Mellitus

• ACE inhibitor or ARB is the preferred initial agent 1, 2
• For diabetes with severely increased albuminuria (≥300 mg/day), ACE inhibitor or ARB is mandatory first-line therapy 1, 2
• Target <130/80 mm Hg 1, 2
• Critical warning: Do not combine intensive systolic lowering (target <120 mm Hg) with intensive glucose lowering (HbA1c <7%), as ACCORD BP trial showed increased serious adverse events 1

Chronic Kidney Disease

• ACE inhibitor or ARB is first-line for CKD stage 3+ or albuminuria ≥300 mg/day 1, 2
• Target <130/80 mm Hg 1, 2
• Use loop diuretics instead of thiazides when eGFR <30 mL/min/1.73m² 1
• Monitor serum creatinine, eGFR, and potassium within 1-2 weeks of initiation, after each dose increase, and annually 2, 4
• Accept creatinine increases up to 50% above baseline or to 3 mg/dL (whichever is greater) 2, 4

Post-Myocardial Infarction or Stable Ischemic Heart Disease

• Combine β-blocker with ACE inhibitor or ARB 2
• Target <130/80 mm Hg 2

Heart Failure with Reduced Ejection Fraction

• Combine ACE inhibitor or ARB, β-blocker, and diuretic 1, 2

Monotherapy vs. Combination Therapy Strategy

Stage 2 hypertension (≥140/90 mm Hg or >20/10 mm Hg above goal) requires immediate two-drug combination therapy, preferably as a single-pill formulation. 1, 2, 4

• Stage 1 hypertension (130-139/80-89 mm Hg): initiate single-agent monotherapy and titrate upward 2
• Two or more medications are required in most adults to achieve <130/80 mm Hg target, especially in Black adults 1
• Submaximal doses of two drugs from different classes produce larger blood pressure reductions with fewer adverse effects than maximal doses of a single agent 2
• Single-pill combinations improve medication adherence and persistence 1, 2, 4

Preferred Two-Drug Combinations

• Thiazide diuretic + (ACE inhibitor or ARB) 1, 2
• Calcium channel blocker + (ACE inhibitor or ARB) 1, 2

Three-Drug Regimen (If Target Not Achieved)

• Switch to single-pill combination of ACE inhibitor or ARB + calcium channel blocker + thiazide diuretic 1

Resistant Hypertension (≥3 Drugs Including Diuretic)

• Add spironolactone (mineralocorticoid receptor antagonist) as fourth agent 1, 2
• Consider α-blocker or β-blocker as alternatives 1
• Refer to hypertension specialist if uncontrolled after 6 months 2

Medications to Avoid as First-Line

β-blockers should not be used as first-line therapy in uncomplicated hypertension, especially in patients >60 years, because they are 36% less effective than calcium channel blockers and 30% less effective than thiazides for stroke prevention. 2

• α-blockers are less effective for cardiovascular disease prevention than thiazide diuretics 2
• Never combine ACE inhibitor + ARB + direct renin inhibitor—this increases adverse effects without benefit 1, 2, 4
• Never combine ACE inhibitor with ARB (dual renin-angiotensin system blockade)—contraindicated due to increased harm 1, 2, 4, 5

Follow-Up Monitoring Schedule

After initiating or adjusting antihypertensive therapy, review patients monthly until blood pressure target is achieved, then every 3-5 months for maintenance. 2, 4

• Space dose adjustments at least 4 weeks apart to allow full blood pressure response 2, 4
• Baseline laboratory evaluation: serum creatinine, eGFR, potassium, fasting glucose, lipid panel 2
• When prescribing ACE inhibitors, ARBs, or diuretics: repeat creatinine, eGFR, and potassium within 1-2 weeks of initiation, after each dose increase, and annually 2, 4, 5
• Out-of-office blood pressure monitoring (home or ambulatory) is essential to assess treatment response, detect white-coat effect, and identify masked uncontrolled hypertension 2

Critical Contraindications and Warnings

ACE inhibitors and ARBs are absolutely contraindicated in pregnancy due to fetal toxicity—women of childbearing age must use reliable contraception. 2, 4, 5

• Women who become pregnant while on ACE inhibitor or ARB must be switched immediately to methyldopa, nifedipine, or labetalol 2
• ACE inhibitors are contraindicated in bilateral renal artery stenosis 4
• Use caution with ACE inhibitors/ARBs in patients with hypotension, renal failure, or hyperkalemia 4

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 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
• Initiating therapy with α-blockers or central α-agonists is associated with higher adverse-effect rates, especially in elderly 2
• Failing to employ out-of-office blood pressure monitoring can miss white-coat or masked hypertension, compromising management 2
• Therapeutic inertia—avoid delaying treatment beyond 3 months in patients with confirmed hypertension ≥140/90 mm Hg 2