What are the current adult hypertension guidelines for treatment initiation thresholds, target blood pressure, lifestyle modifications, first‑line pharmacologic agents, and special population considerations?

Adult Hypertension Guidelines

Blood Pressure Classification and Diagnosis

The 2017 ACC/AHA guideline defines hypertension 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

• This lower threshold (130/80 mm Hg) increased U.S. hypertension prevalence from 32% to 46%, representing a significant shift from the traditional 140/90 mm Hg cutoff still used by WHO and other international guidelines 1
• Normal blood pressure is defined as <120/70 mm Hg 1
• Out-of-office blood pressure monitoring (home or ambulatory) is essential to confirm the diagnosis, exclude white-coat hypertension, and detect masked hypertension 1

Treatment Initiation Thresholds

For patients with stage 2 hypertension (≥140/90 mm Hg), initiate pharmacologic therapy immediately alongside lifestyle modifications. 1

For stage 1 hypertension (130–139/80–89 mm Hg):

• Start medication if the patient has established cardiovascular disease OR 10-year ASCVD risk ≥10% (calculated using ACC/AHA Pooled Cohort Equations) 2, 1
• Start medication if the patient has diabetes mellitus, chronic kidney disease, or hypertension-mediated organ damage 1
• For patients with 10-year ASCVD risk 5–10%, consider additional risk modifiers before initiating therapy 1
• If none of the above apply, implement lifestyle modifications for 3 months; if blood pressure remains ≥130/80 mm Hg after this period, initiate pharmacologic therapy 1

Blood Pressure Treatment Targets

The target blood pressure for most adults is <130/80 mm Hg. 2, 1

Specific population targets:

• Adults <65 years with confirmed hypertension: <130/80 mm Hg 1
• Non-institutionalized, ambulatory adults ≥65 years: systolic <130 mm Hg 1
• Patients with diabetes mellitus: <130/80 mm Hg 2, 1
• Patients with chronic kidney disease: <130/80 mm Hg 1
• Patients with stable ischemic heart disease: <130/80 mm Hg 2, 1
• Patients with prior stroke or TIA: <130/80 mm Hg may be reasonable 2

Critical diastolic consideration: In high-risk patients (especially those with coronary artery disease or age ≥65 years), avoid lowering diastolic blood pressure below 60–70 mm Hg; the optimal diastolic range is 70–79 mm Hg 1

Lifestyle Modifications

All patients with blood pressure ≥120/70 mm Hg should adopt the following lifestyle measures before or alongside pharmacologic therapy: 1

• Sodium restriction: <2,300 mg/day 1
• Weight reduction: if BMI >25 kg/m² 1
• Physical activity: ≥150 minutes/week of moderate-to-vigorous aerobic exercise 1
• DASH dietary pattern: emphasizing fruits, vegetables, whole grains, low-fat dairy, and reduced saturated fat 1, 3
• Alcohol limitation: <14 units/week for men, <8 units/week for women 1
• Potassium supplementation: through dietary sources unless contraindicated 3

These interventions provide additive blood pressure reductions of approximately 4–11 mm Hg systolic and enhance medication efficacy 3

First-Line Pharmacologic Agents

Four drug classes are endorsed as first-line therapy, all with comparable efficacy (approximately 9/5 mm Hg office reduction): 1, 4

1. Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide)
2. ACE inhibitors (e.g., enalapril, lisinopril)
3. Angiotensin receptor blockers (ARBs) (e.g., candesartan, losartan)
4. Long-acting dihydropyridine calcium channel blockers (CCBs) (e.g., amlodipine)

Thiazide diuretics, particularly chlorthalidone, may provide optimal first-line therapy based on superior prevention of heart failure compared with CCBs and superior stroke prevention compared with ACE inhibitors. 1, 4

Population-Specific First-Line Choices

• General (non-Black) population: Any of the four first-line classes 1
• Black patients without heart failure or CKD: Thiazide diuretics or CCBs are preferred; ACE inhibitors and ARBs are less effective for stroke and heart failure prevention in this population 1, 5
• Diabetes mellitus: ACE inhibitor or ARB preferred 2, 1
• Chronic kidney disease (stage 3+ or albuminuria ≥300 mg/day): ACE inhibitor or ARB first-line 1
• Post-myocardial infarction or stable ischemic heart disease: Beta blocker + ACE inhibitor or ARB 2
• Heart failure with reduced ejection fraction: ACE inhibitor or ARB + beta blocker + diuretic 2

Treatment Strategy: Monotherapy vs. Combination Therapy

Stage 1 hypertension (130–139/80–89 mm Hg): Start with single-agent monotherapy and titrate upward before adding a second agent from a different class 1, 4

Stage 2 hypertension (≥140/90 mm Hg or >20/10 mm Hg above goal): Initiate with a two-drug combination from different first-line classes, preferably as a single-pill formulation 1, 4

• Combination therapy using two submaximal doses from different classes yields larger blood pressure reductions with fewer adverse effects than maximal dosing of a single agent 1
• Single-pill combinations improve medication adherence and persistence 1, 4

Preferred two-drug combinations: 1

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

Three-drug regimen for resistant hypertension: ACE inhibitor or ARB + CCB + thiazide diuretic 1

Agents to Avoid as First-Line Therapy

• Beta blockers: Should not be used as first-line therapy in uncomplicated hypertension, especially in patients >60 years, because they are approximately 36% less effective than CCBs and 30% less effective than thiazides for stroke prevention 1, 4
• Alpha blockers: Less effective for cardiovascular disease prevention than thiazide diuretics 1
• Central alpha agonists: Associated with higher adverse-effect rates, particularly in elderly patients 1, 4

Contraindicated combinations: ACE inhibitor + ARB + direct renin inhibitor should be avoided due to increased adverse effects without added benefit 1

Monitoring and Follow-Up

After initiating or adjusting antihypertensive therapy: 1, 4

• Schedule monthly follow-up visits until blood pressure target is achieved
• Once at goal, conduct follow-up every 3–5 months for maintenance
• Space dose adjustments at least 4 weeks apart to allow full blood pressure response 1

Laboratory monitoring: 1

• Baseline: serum creatinine, eGFR, potassium, fasting glucose, lipid panel
• 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
• An increase in serum creatinine up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable 1

Special Population Considerations

Pregnancy

• Switch to methyldopa, nifedipine, or labetalol if a woman becomes pregnant while on antihypertensive therapy 1
• ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated in pregnancy due to fetal toxicity 1

Older Adults (≥65 years)

• Non-institutionalized, ambulatory adults ≥65 years with systolic ≥130 mm Hg should be treated to systolic <130 mm Hg 1
• Exercise caution when initiating combination therapy in older adults at risk for orthostatic hypotension 1
• For frail patients with high comorbidity burden or limited life expectancy, individualized clinical judgment is reasonable; consider deferring treatment until blood pressure exceeds 140/90 mm Hg 1

Resistant Hypertension

Defined as blood pressure ≥130/80 mm Hg despite ≥3 antihypertensive agents at optimal doses (including a diuretic), or blood pressure <130/80 mm Hg requiring ≥4 agents. 1

Systematic approach: 1

1. Confirm true resistance by excluding white-coat effect with out-of-office monitoring and assessing medication adherence
2. Identify contributing lifestyle factors (obesity, excess alcohol, high sodium intake, NSAIDs)
3. Screen for secondary causes (primary aldosteronism, CKD, renal artery stenosis, pheochromocytoma, obstructive sleep apnea)
4. Optimize diuretic therapy; use loop diuretics in patients with CKD
5. Add a mineralocorticoid receptor antagonist (e.g., spironolactone)
6. Refer to a hypertension specialist if uncontrolled after 6 months

Common Pitfalls to Avoid

• Delaying combination therapy in stage 2 hypertension (≥140/90 mm Hg) increases cardiovascular risk 1
• Using beta blockers as first-line agents in patients >60 years without a compelling indication leads to inferior stroke prevention 1, 4
• Excessive diastolic lowering below 60 mm Hg in high-risk patients may increase adverse cardiovascular events 1
• Combining an ACE inhibitor with an ARB (or adding a direct renin inhibitor) should be avoided due to lack of benefit and higher adverse-event risk 1
• Continuing ACE inhibitors or ARBs during pregnancy is contraindicated because of fetal toxicity 1
• Failing to employ out-of-office blood pressure monitoring can miss white-coat or masked hypertension, compromising management 1
• Initiating therapy with alpha blockers or central alpha agonists is associated with higher adverse-effect rates, especially in the elderly 1, 4