What is the recommended approach to managing hypertension in adults, including blood pressure targets, lifestyle modifications, and first‑line pharmacologic therapy?

Hypertension Management in Adults

Blood Pressure Targets

For most adults with confirmed hypertension, target a systolic blood pressure of 120–129 mmHg and diastolic 70–79 mmHg, provided treatment is well tolerated. 1

• Adults younger than 65 years with established cardiovascular disease or 10-year ASCVD risk ≥10% should achieve <130/80 mmHg 2
• Non-institutionalized adults ≥65 years should target systolic <130 mmHg 2
• Patients with diabetes mellitus or chronic kidney disease require <130/80 mmHg 2
• Patients with stable ischemic heart disease need <130/80 mmHg 2
• Avoid lowering diastolic pressure below 70 mmHg in high-risk patients, as excessive reduction may increase adverse cardiovascular events 1, 2
• If the 120–129 mmHg systolic target is poorly tolerated, apply the "as low as reasonably achievable" (ALARA) principle 1

Lifestyle Modifications

All individuals with blood pressure ≥120/70 mmHg must adopt comprehensive lifestyle measures before or alongside pharmacologic therapy. 1

• Weight reduction: Each 1 kg loss reduces systolic BP by approximately 1 mmHg 3
• DASH dietary pattern: Emphasize fruits, vegetables, low-fat dairy, whole grains, and reduced saturated fat 3, 4
• Sodium restriction: Limit intake to <2 g/day (5 g salt); each 1 g reduction lowers systolic BP by 2–3 mmHg 3
• Potassium supplementation: Target 3.5–5 g/day through diet unless contraindicated by CKD 3
• Regular aerobic exercise: ≥150 minutes/week of moderate-intensity activity 3
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 3
• Smoking cessation: Tobacco use independently causes cardiovascular events and mortality 1
• The blood pressure-lowering effects of individual lifestyle components are partially additive and enhance pharmacologic efficacy 3

When to Initiate Pharmacologic Therapy

Confirmed Hypertension (≥140/90 mmHg)

Start lifestyle measures and pharmacologic treatment simultaneously; do not delay beyond initial diagnosis. 1

• Prompt initiation reduces cardiovascular risk regardless of baseline CVD risk 1
• Treatment should be maintained lifelong, even beyond age 85 years, if well tolerated 1

Elevated Blood Pressure (120–139/70–89 mmHg)

Begin with lifestyle modifications alone for 3 months, then add pharmacologic therapy if BP remains ≥130/80 mmHg AND the patient has: 1

• 10-year CVD risk ≥10% (calculated via ACC/AHA Pooled Cohort Equations) 2
• Established cardiovascular disease 2
• Diabetes mellitus 2
• Chronic kidney disease 2
• Hypertension-mediated organ damage 2

Note: Virtually all adults ≥70 years and most ≥65 years have 10-year ASCVD risk ≥10%, meeting the threshold for treatment at elevated BP levels 2

First-Line Pharmacologic Therapy

Drug Class Selection

Four classes are endorsed as first-line: thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, and long-acting dihydropyridine calcium-channel blockers. 1, 3

Among these, thiazide-like diuretics (chlorthalidone or indapamide) provide the strongest cardiovascular outcome evidence and are optimal for initial therapy in the general population. 1, 2, 5

• Chlorthalidone is preferred over hydrochlorothiazide because it delivers superior 24-hour BP reduction and demonstrated greater stroke prevention (vs. lisinopril) and heart failure prevention (vs. amlodipine) in the ALLHAT trial of >50,000 participants 2, 5
• All four first-line classes reduce BP by approximately 9/5 mmHg (office) and 5/3 mmHg (ambulatory) when used as monotherapy 2

Monotherapy vs. Combination Therapy

Stage 1 hypertension (130–139/80–89 mmHg): Start with single-agent monotherapy and titrate upward before adding a second drug 2, 5

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

• Combination therapy using two submaximal doses from different classes yields larger BP reductions with fewer adverse effects than maximal dosing of a single agent 2
• Single-pill combinations markedly improve medication adherence and persistence compared with separate pills 2

Preferred Two-Drug Combinations

Use either: 1, 2

1. RAS blocker (ACE inhibitor or ARB) + thiazide/thiazide-like diuretic
2. RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium-channel blocker

Escalation to Triple Therapy

If BP remains uncontrolled on a two-drug combination, increase to a three-drug regimen: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic, preferably in a single-pill combination. 1

Population-Specific First-Line Choices

Black Patients Without Heart Failure or CKD

Initiate therapy with a thiazide diuretic or calcium-channel blocker. 2, 5

• ACE inhibitors and ARBs are approximately 30–36% less effective for stroke prevention in Black patients because of lower renin activity 2
• ARBs may cause less cough and angioedema than ACE inhibitors but confer no additional cardiovascular benefit 2

Patients with Diabetes Mellitus

Prefer an ACE inhibitor or ARB as initial therapy to protect renal function. 1, 2, 5

• All four first-line classes are acceptable when no albuminuria or renal indication exists 1
• Target BP <130/80 mmHg 1, 2

Patients with Chronic Kidney Disease (Stage 3+ or Albuminuria ≥300 mg/day)

An ACE inhibitor or ARB is mandatory first-line therapy to slow kidney disease progression and reduce proteinuria. 2, 5

• Target BP <130/80 mmHg 2

Post-Myocardial Infarction or Stable Ischemic Heart Disease

Combine a β-blocker with an ACE inhibitor or ARB. 2

• Target BP <130/80 mmHg 2

Heart Failure with Reduced Ejection Fraction

Use a three-drug regimen: ACE inhibitor or ARB + β-blocker + diuretic. 2

Pregnancy

Switch to methyldopa, extended-release nifedipine, or labetalol. 1

• ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated in pregnancy due to fetal toxicity 2
• Initiate treatment when confirmed office BP ≥140/90 mmHg 1
• Target BP <140/90 mmHg but not <80 mmHg diastolic 1

Agents NOT Recommended as First-Line

β-Blockers

Do not use β-blockers as first-line therapy in uncomplicated hypertension, especially in patients >60 years. 2, 5

• They are approximately 36% less effective than CCBs and 30% less effective than thiazides for stroke prevention 2
• Reserve β-blockers for compelling indications: angina, post-MI, heart failure with reduced ejection fraction, or heart rate control 1

α-Blockers

Not recommended as first-line because they are less effective for cardiovascular disease prevention than thiazide diuretics. 2

Critical Contraindications

Never combine an ACE inhibitor with an ARB (or add a direct renin inhibitor). 1, 2

• This dual RAS blockade increases risk of hyperkalemia and acute kidney injury without added cardiovascular benefit 2

Monitoring and Follow-Up

Visit Schedule

Review patients monthly after initiating or adjusting therapy until BP target is achieved, then every 3–5 months for maintenance. 2, 5

• Space dose adjustments at least 4 weeks apart to allow full BP response 2

Laboratory Monitoring

Baseline: 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 thereafter 2, 5

• An increase in serum creatinine up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable 2

Out-of-Office Blood Pressure Monitoring

Home BP monitoring or ambulatory BP monitoring is essential to assess treatment response, detect white-coat effect, and identify masked uncontrolled hypertension. 2, 6

• Systematic home BP monitoring combined with team-based care and telehealth improves BP control 2

Special Considerations

Young Adults (<40 Years)

Perform comprehensive screening for secondary hypertension causes (renal artery stenosis, primary aldosteronism, pheochromocytoma, Cushing syndrome, coarctation of the aorta). 1

• Exception: In obese young adults, start with obstructive sleep apnea evaluation 1

Older Adults (≥85 Years)

Continue BP-lowering treatment lifelong if well tolerated. 1

• Consider exceptions for patients with symptomatic orthostatic hypotension, moderate-to-severe frailty, or high comorbidity burden 1
• Asymptomatic orthostatic hypotension should not prompt treatment withdrawal 1

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, 2

Systematic approach: 2

1. Confirm true resistance with out-of-office monitoring and assess medication adherence
2. Identify contributing factors: obesity, excess alcohol, high sodium intake, NSAIDs, obstructive sleep apnea
3. Screen for secondary causes: primary aldosteronism (all patients with difficult-to-control or resistant hypertension should be screened), CKD, renal artery stenosis, pheochromocytoma 1, 2
4. Optimize diuretic therapy; use loop diuretics in CKD
5. Add a mineralocorticoid-receptor antagonist (spironolactone)
6. Refer to a hypertension specialist if uncontrolled after 6 months

Renal denervation is not recommended as first-line therapy due to lack of adequately powered outcomes trials demonstrating safety and CVD benefits. 1

Common Pitfalls to Avoid

• Delaying combination therapy in stage 2 hypertension (≥140/90 mmHg) increases cardiovascular risk 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 mmHg in high-risk patients may increase adverse cardiovascular events 1, 2
• Failing to employ out-of-office BP monitoring can miss white-coat or masked hypertension, compromising management 2, 6
• Diagnosing hypertension on a single office measurement without confirmation on separate occasions or out-of-office monitoring 6
• Continuing ACE inhibitors or ARBs during pregnancy is contraindicated due to fetal toxicity 2