What are the current hypertension (high blood pressure) management guidelines, including diagnostic blood pressure thresholds, lifestyle modifications, and first‑line pharmacologic choices based on age, cardiovascular risk, and comorbidities such as diabetes, chronic kidney disease, or African‑American ethnicity?

Hypertension Management Guidelines

Blood Pressure Thresholds and Diagnosis

Hypertension is defined as persistent systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg, and diagnosis should be confirmed with home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before initiating treatment. 1, 2

• Stage 1 hypertension is defined as systolic 130–139 mmHg or diastolic 80–89 mmHg 2
• Stage 2 hypertension is defined as systolic ≥160 mmHg or diastolic ≥100 mmHg and warrants immediate dual pharmacologic therapy 1
• Confirm elevated office readings with out-of-office monitoring to exclude white-coat hypertension before escalating therapy 1, 3

Blood Pressure Targets

Target blood pressure is <130/80 mmHg for most adults, with a minimum acceptable goal of <140/90 mmHg. 1, 2

• For adults ≥65 years, target systolic blood pressure is <130 mmHg 2
• For higher-risk patients (diabetes, chronic kidney disease, established cardiovascular disease), target is <130/80 mmHg 1
• Optimal target is 120–129 mmHg systolic if well tolerated 1
• Individualize targets for elderly patients based on frailty, but do not withhold appropriate treatment solely based on age 1

Lifestyle Modifications (First-Line for All Patients)

All patients with elevated blood pressure should receive counseling on lifestyle interventions, which can provide additive blood pressure reductions of 10–20 mmHg systolic. 1, 2

• Sodium restriction to <2 g/day yields 5–10 mmHg systolic reduction 1, 2
• DASH dietary pattern (high in fruits, vegetables, whole grains, low-fat dairy; low in saturated fat) reduces blood pressure by approximately 11.4/5.5 mmHg 1, 2
• Weight loss of approximately 10 kg in overweight/obese patients decreases blood pressure by roughly 6.0/4.6 mmHg 1, 2
• Regular aerobic exercise (≥30 minutes most days, ≈150 minutes/week moderate intensity) lowers blood pressure by approximately 4/3 mmHg 1, 2
• Limit alcohol to ≤2 drinks/day for men and ≤1 drink/day for women 1, 2

Pharmacologic Therapy: First-Line Agents

First-line antihypertensive medications include thiazide or thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs). 2, 4

For Non-Black Patients Without Compelling Indications

• Start with an ACE inhibitor (e.g., lisinopril 10 mg, titratable to 20–40 mg) or ARB (e.g., losartan 50 mg, titratable to 100 mg) 1, 3
• If blood pressure remains uncontrolled, add a dihydropyridine calcium channel blocker (e.g., amlodipine 5–10 mg daily) as the second agent 1, 3
• If blood pressure remains uncontrolled on dual therapy, add a thiazide-like diuretic (chlorthalidone 12.5–25 mg daily or hydrochlorothiazide 25 mg daily) as the third agent 1, 3
• Chlorthalidone is preferred over hydrochlorothiazide due to its longer duration of action (24–72 hours vs 6–12 hours) and superior cardiovascular outcome data from the ALLHAT trial 1

For Black Patients

• Start with a dihydropyridine calcium channel blocker (e.g., amlodipine 5–10 mg daily) as initial therapy 1
• If blood pressure remains uncontrolled, add either a thiazide-like diuretic or an ACE inhibitor/ARB as the second agent 1, 3
• The combination of calcium channel blocker plus thiazide diuretic may be more effective than calcium channel blocker plus ACE inhibitor/ARB in Black patients 1

For Patients with Stage 2 Hypertension (≥160/100 mmHg)

• Initiate dual therapy immediately with two agents from different classes (or a single-pill combination) 1
• Typical combinations include ACE inhibitor/ARB + calcium channel blocker, or ACE inhibitor/ARB + thiazide diuretic 1

Pharmacologic Therapy: Compelling Indications

Diabetes Mellitus

• ACE inhibitors or ARBs are preferred first-line agents due to renoprotective effects 1, 5
• Target blood pressure is <130/80 mmHg 1
• The combination of ACE inhibitor + calcium channel blocker + thiazide diuretic has demonstrated superior blood pressure control in patients with diabetes 1

Chronic Kidney Disease

• ACE inhibitors or ARBs are preferred first-line agents to slow progression of kidney disease and lower albuminuria 1, 5
• Target blood pressure is <130/80 mmHg 1
• Monitor serum potassium and creatinine 2–4 weeks after initiating or uptitrating ACE inhibitors/ARBs 1

Heart Failure with Reduced Ejection Fraction

• ACE inhibitors or ARBs are preferred first-line agents 1
• Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) should be added for compelling indication 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to negative inotropic effects 1

Coronary Artery Disease or Post-Myocardial Infarction

• Beta-blockers are indicated as first-line agents 1
• ACE inhibitors or ARBs should be added for additional cardiovascular protection 1

Atrial Fibrillation Requiring Rate Control

• Beta-blockers or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are indicated 1

Triple Therapy for Uncontrolled Hypertension

When blood pressure remains uncontrolled on dual therapy, escalate to triple therapy with an ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic. 1, 2

• This combination targets three complementary mechanisms: renin-angiotensin system blockade, vasodilation, and volume reduction 1
• Fixed-dose single-pill combinations are strongly recommended to improve medication adherence 1
• Reassess blood pressure within 2–4 weeks after adding the third agent, with the goal of achieving target blood pressure within 3 months 1, 3

Resistant Hypertension (Fourth-Line Therapy)

If blood pressure remains ≥140/90 mmHg despite optimized triple therapy (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic at maximum tolerated doses), add spironolactone 25–50 mg daily as the preferred fourth-line agent. 1, 3

• Spironolactone provides additional blood pressure reductions of approximately 20–25 mmHg systolic and 10–12 mmHg diastolic when added to triple therapy 1
• Check serum potassium and creatinine 2–4 weeks after initiating spironolactone due to increased hyperkalemia risk when combined with ACE inhibitors/ARBs 1
• Alternative fourth-line agents if spironolactone is contraindicated include amiloride, eplerenone, doxazosin, or clonidine 1, 3
• Refer to a hypertension specialist if blood pressure remains uncontrolled (≥160/100 mmHg) despite four-drug therapy at optimal doses 1, 3

Critical Steps Before Intensifying Therapy

Verify medication adherence first, as non-adherence is the most common cause of apparent treatment resistance. 1, 3

• Use direct questioning, pill counts, or pharmacy refill records to assess adherence 1
• Review for interfering medications: NSAIDs, decongestants, oral contraceptives, systemic corticosteroids, and herbal supplements (ephedra, St. John's wort, licorice) can all elevate blood pressure 1
• Screen for secondary hypertension if blood pressure remains severely elevated (≥180/110 mmHg) or resistant to triple therapy: evaluate for primary aldosteronism, renal artery stenosis, obstructive sleep apnea, and pheochromocytoma 1

Monitoring and Follow-Up

• Reassess blood pressure within 2–4 weeks after any medication change 1, 3
• Check serum potassium and creatinine 2–4 weeks after initiating ACE inhibitors, ARBs, or diuretics 1
• Aim to achieve target blood pressure within 3 months of initiating or modifying therapy 1, 3

Common Pitfalls to Avoid

• Do not combine an ACE inhibitor with an ARB (dual renin-angiotensin system blockade), as this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit 1, 2
• Do not add a beta-blocker as the second or third agent unless there are compelling indications (angina, post-myocardial infarction, heart failure with reduced ejection fraction, atrial fibrillation), as beta-blockers are less effective than calcium channel blockers or diuretics for stroke prevention 1
• Do not delay treatment intensification when blood pressure remains uncontrolled; stage 2 hypertension (≥160/100 mmHg) requires prompt action within 2–4 weeks to reduce cardiovascular risk 1
• Do not add a third drug class before maximizing doses of the current two-drug regimen, as this violates guideline-recommended stepwise approaches 1
• Do not assume treatment failure without first confirming adherence and ruling out secondary causes of hypertension 1, 3

Special Populations

Elderly Patients (≥75 Years)

• Target systolic blood pressure is <130 mmHg if tolerated 1
• Individualize targets based on frailty, but do not withhold appropriate treatment solely based on age 1
• Thiazide diuretics should be used cautiously in elderly women with urinary incontinence, as they increase nocturia and urinary frequency 1

Patients with COPD or Asthma

• Calcium channel blockers and ACE inhibitors/ARBs are safe and preferred 1
• Beta-blockers are contraindicated unless there is a compelling indication (recent myocardial infarction, heart failure, angina) 1

Patients with Obesity or Metabolic Syndrome

• Calcium channel blockers and ACE inhibitors/ARBs are weight-neutral and do not adversely affect glucose or lipid metabolism 1
• Avoid beta-blockers as a third agent unless there are compelling indications, as they can decrease metabolic rate and are associated with weight gain 1