What is the recommended management plan for hypertension in adults, including blood pressure targets, lifestyle modifications, criteria for initiating pharmacotherapy, first‑line medication choices based on comorbidities, and follow‑up monitoring?

Management of Hypertension in Adults

Blood Pressure Targets

For most adults with hypertension, target a blood pressure <130/80 mmHg to maximize cardiovascular protection. 1

• Adults <65 years: Target <130/80 mmHg 1
• Adults ≥65 years (ambulatory, non-institutionalized): Target systolic <130 mmHg 1, 2
• Patients with diabetes mellitus: Target <130/80 mmHg 3, 1
• Patients with chronic kidney disease: Target <130/80 mmHg 1
• Patients with stable ischemic heart disease: Target <130/80 mmHg 1
• High-risk patients: Avoid lowering diastolic pressure below 70 mmHg, as excessive reduction increases adverse cardiovascular events; optimal diastolic range is 70–79 mmHg 1

Lifestyle Modifications

All patients with blood pressure ≥120/70 mmHg should adopt comprehensive lifestyle measures immediately, not sequentially with pharmacotherapy. 1, 4

• Weight loss to achieve BMI <25 kg/m² 1
• DASH dietary pattern emphasizing fruits, vegetables, whole grains, and low-fat dairy 1, 5
• Sodium restriction to <2 g/day (ideally <1.5 g/day) 1, 5
• Potassium supplementation to 3.5–5 g/day through diet 1, 5
• Aerobic physical activity 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous-intensity exercise 1, 5
• Alcohol moderation to ≤2 drinks/day for men, ≤1 drink/day for women 1, 5
• Smoking cessation to independently reduce cardiovascular mortality 1

Criteria for Initiating Pharmacotherapy

Stage 2 hypertension (≥140/90 mmHg): Begin pharmacologic therapy immediately alongside lifestyle modification; do not delay beyond 3 months. 1, 4

Stage 1 hypertension (130–139/80–89 mmHg): Initiate medication when any of the following are present: 1, 4

• Established atherosclerotic cardiovascular disease 1, 4
• 10-year ASCVD risk ≥10% (ACC/AHA Pooled Cohort Equations) 1, 4
• Diabetes mellitus 1, 4
• Chronic kidney disease (stage 3+ or albuminuria ≥300 mg/day) 1, 4
• Hypertension-mediated organ damage 1, 4

Elevated blood pressure (120–129/70–79 mmHg): Trial lifestyle modification for 3 months; add pharmacotherapy if BP remains ≥130/80 mmHg and patient meets above criteria. 1

First-Line Medication Choices

General Adult Population (Non-Black, No Compelling Indications)

Initiate with chlorthalidone 12.5–25 mg once daily as the optimal first-line agent; it provides superior cardiovascular protection compared to ACE inhibitors and calcium channel blockers. 1

• Chlorthalidone reduced heart failure by 38% versus amlodipine and stroke by 15% versus lisinopril in the ALLHAT trial (>50,000 participants) 1
• Alternative first-line agents include long-acting dihydropyridine CCBs (amlodipine 5–10 mg daily), ACE inhibitors (lisinopril 10–40 mg daily), or ARBs (losartan 50–100 mg daily) 1, 5

Black Patients Without Heart Failure or CKD

Begin with a thiazide diuretic (chlorthalidone) or calcium channel blocker (amlodipine); ACE inhibitors and ARBs are 30–36% less effective for stroke prevention in this population. 1, 4, 2

Patients with Diabetes Mellitus

Prefer an ACE inhibitor or ARB as initial therapy to protect renal function, especially when albuminuria ≥300 mg/day is present. 3, 1

• Target BP <130/80 mmHg 3, 1
• For systolic 130–139 mmHg or diastolic 80–89 mmHg: trial lifestyle modification for maximum 3 months, then add ACE inhibitor or ARB if target not achieved 3
• For systolic ≥140 mmHg or diastolic ≥90 mmHg: initiate drug therapy immediately alongside lifestyle modification 3

Patients with Chronic Kidney Disease

Use an ACE inhibitor or ARB as first-line therapy to slow eGFR decline and reduce proteinuria. 1, 4

• Target BP <130/80 mmHg 1
• Thiazide diuretics remain effective even when eGFR <30 mL/min/1.73 m² and should not be avoided 1

Patients with Stable Ischemic Heart Disease or Post-MI

Combine a β-blocker with an ACE inhibitor or ARB as initial therapy. 1

• Target BP <130/80 mmHg 1

Patients with Heart Failure with Reduced Ejection Fraction

Use triple therapy: ACE inhibitor or ARB + β-blocker + diuretic. 1

Monotherapy vs. Combination Therapy Strategy

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

Stage 2 hypertension (≥140/90 mmHg or >20/10 mmHg above goal): Begin with a two-drug combination from different first-line classes, preferably as a single-pill formulation to improve adherence. 1, 4

Preferred Two-Drug Combinations

• ACE inhibitor or ARB + thiazide diuretic (optimal for general population) 1, 4
• ACE inhibitor or ARB + long-acting dihydropyridine CCB (when thiazides contraindicated) 1, 4
• For Black patients: Thiazide diuretic + CCB 1, 4

Escalation to Triple Therapy

If BP remains ≥140/90 mmHg despite dual therapy at optimal doses for 3 months, add a third agent to create: ACE inhibitor or ARB + CCB + thiazide diuretic, preferably as a single-pill combination. 1, 4

Agents to Avoid as First-Line

β-blockers should not be used as first-line therapy in uncomplicated hypertension, especially in patients >60 years, because they are 36% less effective than CCBs and 30% less effective than thiazides for stroke prevention. 1, 2

α-blockers are not first-line agents; doxazosin increased heart failure by 80% versus chlorthalidone in ALLHAT. 1

Never combine an ACE inhibitor with an ARB (or add a direct renin inhibitor); dual RAS blockade increases hyperkalemia and acute kidney injury without added cardiovascular benefit. 1, 4, 2

Follow-Up Monitoring

Schedule monthly follow-up visits after initiating or adjusting therapy until BP target is achieved; thereafter, see patients every 3–5 months for maintenance. 1, 4, 2

• Allow at least 4 weeks between dose adjustments to observe full BP response 2
• Obtain baseline serum creatinine, eGFR, potassium, fasting glucose, and lipid panel before starting therapy 1
• 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 3, 1, 2
• An increase in serum creatinine up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable 1, 2
• Use out-of-office BP monitoring (home target <135/85 mmHg or 24-hour ambulatory target <130/80 mmHg) to confirm treatment response and detect white-coat or masked hypertension. 1, 4

Special Population Considerations

Pregnancy

Switch to methyldopa, extended-release nifedipine, or labetalol; ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated due to fetal toxicity. 1, 2

Older Adults ≥85 Years

Continue BP-lowering treatment lifelong if well tolerated; asymptomatic orthostatic hypotension should not prompt withdrawal. 1

• Exercise caution when initiating combination therapy in those at risk for symptomatic orthostatic hypotension 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

Systematic approach: 1

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, renal artery stenosis, pheochromocytoma, Cushing syndrome
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

Common Pitfalls to Avoid

Delaying combination therapy in stage 2 hypertension increases cardiovascular risk; begin two-drug therapy immediately. 1

Using β-blockers as first-line in patients >60 years without compelling indications leads to inferior stroke prevention. 1, 2

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

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

Continuing ACE inhibitors or ARBs during pregnancy is contraindicated due to fetal toxicity. 1, 2

Black patients have greater risk of angioedema with ACE inhibitors compared to other populations. 2