What are the American Heart Association guidelines for managing hypertension in adults, including target blood pressure, lifestyle modifications, first‑line pharmacologic therapy, combination treatment, resistant hypertension management, and monitoring?

American Heart Association Guidelines for Blood Pressure Control

The 2017 ACC/AHA guideline recommends a target blood pressure of <130/80 mm Hg for most adults with hypertension, with treatment initiated at BP ≥130/80 mm Hg in patients with known cardiovascular disease or 10-year ASCVD risk ≥10%. 1

Blood Pressure Classification and Diagnosis

The ACC/AHA guideline defines hypertension using the following thresholds 1:

• Normal BP: SBP <120 mm Hg AND DBP <80 mm Hg 1
• Elevated BP: SBP 120-129 mm Hg AND DBP <80 mm Hg 1
• Stage 1 Hypertension: SBP 130-139 mm Hg OR DBP 80-89 mm Hg 1
• Stage 2 Hypertension: SBP ≥140 mm Hg OR DBP ≥90 mm Hg 1

Confirm the diagnosis with out-of-office blood pressure measurements (home monitoring or ambulatory BP monitoring) to detect white coat hypertension or masked hypertension before initiating treatment. 1

Treatment Thresholds Based on Risk Stratification

For Stage 1 Hypertension (BP 130-139/80-89 mm Hg):

• If 10-year ASCVD risk <10%: Initiate lifestyle modifications only, reassess in 3-6 months 1
• If 10-year ASCVD risk ≥10% OR known CVD: Initiate both lifestyle modifications AND pharmacologic therapy, reassess in 1 month 1

For Stage 2 Hypertension (BP ≥140/90 mm Hg):

• Initiate combination therapy with both lifestyle modifications AND two antihypertensive drugs from different classes, particularly when BP is >20/10 mm Hg above target 1
• Evaluate within 1 month of diagnosis 1

For Hypertensive Urgency (BP ≥180/110 mm Hg):

• Prompt evaluation and immediate antihypertensive drug treatment is required 1

Lifestyle Modifications (First-Line for All Patients)

The following nonpharmacologic interventions are recommended for all adults with elevated BP or hypertension 1:

• Weight loss: Target BMI <25 kg/m² 1, 2
• DASH dietary pattern: Emphasize fruits, vegetables, whole grains, low-fat dairy 1, 2
• Sodium restriction: Reduce intake to <1,500 mg/day (ideal) or at least <2,300 mg/day 1, 2
• Potassium supplementation: Increase dietary potassium to 3,500-5,000 mg/day unless contraindicated 1, 2
• Physical activity: 90-150 minutes/week of aerobic exercise and/or dynamic resistance training 1, 2
• Alcohol moderation: Limit to ≤2 drinks/day for men, ≤1 drink/day for women 1, 2

First-Line Pharmacologic Therapy

For Patients Without Compelling Indications:

Initiate therapy with thiazide diuretics (preferably chlorthalidone), calcium channel blockers, ACE inhibitors, or angiotensin receptor blockers. 1

• Thiazide diuretics (especially chlorthalidone) and calcium channel blockers are preferred for most U.S. adults due to superior efficacy in reducing cardiovascular events 1
• For Black patients without heart failure or CKD: Thiazide diuretics or calcium channel blockers are recommended over ACE inhibitors or ARBs as initial therapy 1, 3

Specific Drug Recommendations:

Primary agents 1:

• Thiazide diuretics: Chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to longer half-life and proven CVD reduction) 1
• Calcium channel blockers: Amlodipine 2.5-10 mg daily 1
• ACE inhibitors: Lisinopril 10-40 mg daily, enalapril 5-40 mg daily 1
• ARBs: Losartan 25-100 mg daily, candesartan 8-32 mg daily 1

Compelling Indications for Specific Drug Classes:

• Heart failure or post-MI: ACE inhibitors or ARBs plus beta-blockers 1, 3
• Diabetes with albuminuria: ACE inhibitors or ARBs 3
• Chronic kidney disease: ACE inhibitors or ARBs 1, 3

Combination Therapy Strategy

For Stage 2 hypertension, initiate two-drug combination therapy immediately, preferably as a single-pill combination to improve adherence 1, 3:

• Preferred combinations: Thiazide diuretic + ACE inhibitor/ARB, or calcium channel blocker + ACE inhibitor/ARB 1
• Most patients require at least two drugs to achieve BP goals; submaximal doses of two drugs produce larger BP reductions with fewer side effects than maximal doses of one drug 3

Never combine ACE inhibitors with ARBs or direct renin inhibitors—this increases adverse effects without additional benefit. 1, 3

Target Blood Pressure Goals

General Adult Population:

• Adults <65 years: Target <130/80 mm Hg 1, 2
• Adults ≥65 years (noninstitutionalized, ambulatory): Target SBP <130 mm Hg if tolerated 1

Special Populations:

• Diabetes mellitus: Target <130/80 mm Hg (assume 10-year ASCVD risk ≥10%) 1
• Chronic kidney disease: Target <130/80 mm Hg 1
• Known cardiovascular disease: Target <130/80 mm Hg 1

The lower safety boundary is SBP 120 mm Hg and DBP 70 mm Hg for adults 18-65 years; avoid reducing BP below these thresholds. 1

Resistant Hypertension Management

Resistant hypertension is defined as BP above goal despite adherence to three antihypertensive drugs of different classes (including a diuretic) at maximally tolerated doses. 1

Management approach 1:

1. Confirm true resistance: Rule out white coat effect with ambulatory BP monitoring, assess medication adherence, review interfering substances (NSAIDs, decongestants, licorice) 1
2. Screen for secondary causes: Evaluate for primary aldosteronism, renal artery stenosis, obstructive sleep apnea, pheochromocytoma 1
3. Optimize diuretic therapy: Switch to chlorthalidone if using hydrochlorothiazide; add loop diuretic if eGFR <30 mL/min/1.73m² 1
4. Add spironolactone as fourth-line agent (25-50 mg daily) if potassium <4.5 mEq/L and eGFR >30 mL/min/1.73m² 4

Monitoring and Follow-Up

Initial Phase:

• Monthly evaluation after initiating drug therapy until BP control is achieved 1
• Reassess in 1 month for Stage 2 hypertension on combination therapy 1
• Reassess in 3-6 months for Stage 1 hypertension on lifestyle modifications alone 1

Maintenance Phase:

• Every 3-6 months once BP goal is achieved 1
• Annual reassessment for adults with normal BP 1

Laboratory Monitoring:

• Monitor serum creatinine, eGFR, and potassium within 2-4 weeks after initiating ACE inhibitors, ARBs, or diuretics 1, 3
• Creatinine increase up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable with ACE inhibitors/ARBs 3
• Annual monitoring thereafter for electrolytes and renal function 3

Strategies to Improve BP Control

Implement team-based care approaches involving physicians, nurses, pharmacists, and community health workers to improve adherence and outcomes. 1

Utilize home blood pressure monitoring (HBPM) to detect white coat effect, masked hypertension, and improve medication adherence. 1

Consider single-pill combination therapy whenever possible to enhance adherence—this is strongly favored over separate pills. 1, 3

Use telehealth and health information technology for remote monitoring and self-management support. 1

Critical Safety Considerations

Absolute Contraindications:

• ACE inhibitors/ARBs: Pregnancy (fetal toxicity), bilateral renal artery stenosis, history of angioedema 1, 3
• Spironolactone: Hyperkalemia (K+ >5.0 mEq/L), severe renal impairment (eGFR <30) 4

Important Warnings:

• Black patients have greater risk of angioedema with ACE inhibitors compared to other populations 3
• Allow at least 4 weeks between dose adjustments to observe full BP response unless urgent lowering is required 3
• Avoid beta-blockers as first-line therapy in Black patients due to reduced efficacy 1