What are the current hypertension guidelines for adults regarding blood pressure classification, treatment thresholds, first‑line pharmacologic agents, target blood pressure, and follow‑up?

Hypertension Guidelines for Adults

Blood Pressure Classification

The 2017 ACC/AHA guidelines define hypertension as blood pressure ≥130/80 mmHg, representing a significant departure from the traditional 140/90 mmHg threshold. 1, 2

• Normal BP: <120/<80 mmHg 1, 2
• Elevated BP: 120–129/<80 mmHg 1, 2
• Stage 1 Hypertension: 130–139/80–89 mmHg 1, 2
• Stage 2 Hypertension: ≥140/≥90 mmHg 1, 2, 3

Important caveat: The 2024 European Society of Cardiology (ESC) and World Health Organization (WHO) 2022 guidelines retain the traditional 140/90 mmHg threshold, creating an international divergence in diagnostic criteria. 1 For U.S. practice, the ACC/AHA 130/80 mmHg threshold is the current standard.

Proper Blood Pressure Measurement Technique

Accurate measurement requires: patient seated quietly for ≥5 minutes with back supported, feet flat on floor, arm at heart level, using proper cuff size on bare arm, with no conversation and empty bladder. 2 Out-of-office monitoring (home or ambulatory) is essential to confirm diagnosis and exclude white-coat hypertension. 1, 2

---

Treatment Thresholds: When to Initiate Pharmacologic Therapy

Stage 1 Hypertension (130–139/80–89 mmHg)

Initiate antihypertensive medication when the patient has:

• Established atherosclerotic cardiovascular disease (ASCVD) 1
• 10-year ASCVD risk ≥10% (calculated using ACC/AHA Pooled Cohort Equations) 4, 1
• Diabetes mellitus 1
• Chronic kidney disease (CKD) 1
• Hypertension-mediated organ damage 1

For low-risk Stage 1 patients (10-year ASCVD risk <10%): Begin with lifestyle modifications alone; add pharmacotherapy only if BP remains ≥140/90 mmHg after 3–6 months. 2

Stage 2 Hypertension (≥140/≥90 mmHg)

Initiate both lifestyle modifications AND pharmacologic therapy immediately—do not delay treatment. 1, 2, 3 Virtually all individuals aged 70 and older, and most aged 65 and older, will have a 10-year ASCVD risk ≥10% and therefore qualify for treatment at the Stage 1 threshold. 4

---

First-Line Pharmacologic Agents

Four drug classes are endorsed as first-line therapy with comparable efficacy (approximately 9/5 mmHg office BP reduction): 1

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)

1, 5

Population-Specific First-Line Choices

• General (non-Black) population without compelling indications: Any of the four first-line classes may be selected, though thiazide diuretics (especially chlorthalidone) offer the strongest evidence for cardiovascular outcome benefit, including superior prevention of heart failure compared with CCBs and superior stroke prevention compared with ACE inhibitors. 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 ARBs may cause less cough and angioedema than ACE inhibitors. 1

• Diabetes mellitus: ACE inhibitor or ARB is the preferred initial agent. 1

• Chronic kidney disease (stage 3+ or albuminuria ≥300 mg/day): ACE inhibitor or ARB is first-line. 1

• Post-myocardial infarction or stable ischemic heart disease: Combine a β-blocker with an ACE inhibitor or ARB. 4, 1

• Heart failure with reduced ejection fraction: Combine an ACE inhibitor or ARB, a β-blocker, and a diuretic. 4, 1

Agents to Avoid as First-Line Therapy

• β-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

• α-Blockers are not recommended as first-line agents because they are less effective for cardiovascular disease prevention than thiazide diuretics. 1

---

Monotherapy vs. Combination Therapy Strategy

Stage 1 Hypertension (130–139/80–89 mmHg)

Start with single-agent monotherapy, titrating the dose before adding agents from a different class as needed. 1

Stage 2 Hypertension (≥140/≥90 mmHg or >20/10 mmHg above goal)

Begin treatment with a two-drug combination from different first-line classes, preferably as a single-pill formulation. 1, 3 Single-pill combinations improve medication adherence and persistence compared with separate pills. 1

Preferred two-drug combinations: 1

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

Combination therapy using two submaximal doses from different classes yields larger BP reductions with fewer adverse effects than maximal dosing of a single agent. 1

Contraindicated Combinations

The combination of an ACE inhibitor, an ARB, and a direct renin inhibitor should be avoided due to increased adverse effects without added benefit. 1

---

Target Blood Pressure

For most adults with hypertension, the target blood pressure is <130/80 mmHg. 4, 1, 2, 5

Population-Specific Targets

• Adults <65 years with established CVD or 10-year ASCVD risk ≥10%: <130/80 mmHg (Class I, Level A) 1

• Non-institutionalized, ambulatory adults ≥65 years with average systolic ≥130 mmHg: Systolic <130 mmHg (moderate recommendation) 1 However, caution is advised when initiating combination therapy in older adults at risk for orthostatic hypotension. 1

• Patients with diabetes mellitus: <130/80 mmHg 1, 2

• Patients with chronic kidney disease: <130/80 mmHg 1, 2

• Patients with stable ischemic heart disease: <130/80 mmHg 4, 1

• Patients with prior stroke or TIA: <130/80 mmHg may be reasonable (Class IIa) 1

Diastolic Blood Pressure Considerations

In high-risk patients, diastolic pressure should not be lowered below 60–70 mmHg; the optimal diastolic range is 70–79 mmHg. 1 Excessive diastolic lowering below 60 mmHg may increase adverse cardiovascular events. 1

Special Populations

• Frail patients or those with limited life expectancy: Treatment may be deferred until BP exceeds 140/90 mmHg; individualized clinical judgment and team-based risk-benefit assessment are reasonable. 1

• Adults ≥85 years with symptomatic orthostatic hypotension: A more lenient target of <140/90 mmHg may be considered. 2

---

Follow-Up and Monitoring

After initiating or adjusting antihypertensive therapy, patients should be reviewed monthly until the BP target is achieved. 4, 1, 2, 3

Once the target is reached, conduct follow-up every 3–5 months for maintenance. 1

Dose adjustments should be spaced at least 4 weeks apart to allow full BP response. 1

Laboratory Monitoring

• Baseline evaluation: Serum creatinine, estimated glomerular filtration rate (eGFR), potassium, fasting glucose, and lipid panel 1

• When ACE inhibitors, ARBs, or diuretics are prescribed: Repeat creatinine, eGFR, and potassium within 1–2 weeks of initiation, after each dose increase, and annually thereafter 1

• An increase in serum creatinine of up to 50% above baseline or to 3 mg/dL (whichever is greater) is considered acceptable. 1

Out-of-Office Monitoring

Out-of-office BP monitoring (home or ambulatory) is essential to assess treatment response, detect white-coat effect, and identify masked uncontrolled hypertension. 1, 2 Systematic use of home BP monitoring, team-based care, and telehealth strategies improve BP control (Class I, Level A). 4, 2

---

Resistant Hypertension

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

Systematic Approach to Resistant Hypertension

1. Confirm true resistance by excluding white-coat effect with out-of-office monitoring and assessing adherence 1
2. Identify contributing lifestyle factors (obesity, excess alcohol, high sodium, NSAIDs) 1
3. Screen for secondary causes (primary aldosteronism, CKD, renal artery stenosis, pheochromocytoma, obstructive sleep apnea) 1
4. Optimize diuretic therapy, using loop diuretics in CKD 1
5. Add a mineralocorticoid-receptor antagonist (e.g., spironolactone) as the preferred agent if not contraindicated 1, 2
6. Refer to a hypertension specialist if uncontrolled after 6 months 1

---

Common Pitfalls to Avoid

• Delaying combination therapy in Stage 2 hypertension (≥140/≥90 mmHg) increases cardiovascular risk. 1, 3

• Using β-blockers as first-line agents in patients >60 years without a compelling indication leads to inferior stroke prevention. 1

• Excessive diastolic lowering below 60 mmHg in high-risk patients may increase adverse cardiovascular events. 1

• Initiating therapy with α-blockers or central α-agonists is associated with higher adverse-effect rates, especially in the elderly. 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

• Failing to employ out-of-office BP monitoring can miss white-coat or masked hypertension, compromising management. 1

• Failing to achieve target BP within a reasonable timeframe (3 months) is a common pitfall. 3

• Overlooking the need for more frequent monitoring and follow-up in patients with severe hypertension. 3

---

Pregnancy Considerations

Women who become pregnant while hypertensive should be switched to methyldopa, nifedipine, or labetalol. 1

ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated in pregnancy because of fetal toxicity. 1