What are the current hypertension guidelines for adults, including screening frequency, diagnostic blood pressure threshold, recommended lifestyle modifications, first‑line pharmacologic agents, medication selection based on comorbidities, management of resistant hypertension, special population considerations, and follow‑up schedule?

Hypertension Guidelines for Adults

Blood Pressure Classification and Diagnostic Thresholds

Hypertension is defined as blood pressure ≥130/80 mm Hg based on the 2017 ACC/AHA guideline, representing a significant departure from the traditional 140/90 mm Hg threshold. 1

• Normal BP: <120/<80 mm Hg 1
• Elevated BP: 120–129/<80 mm Hg 1
• Stage 1 hypertension: 130–139/80–89 mm Hg 1
• Stage 2 hypertension: ≥140/≥90 mm Hg 1

The diagnosis must be based on an average of ≥2 careful readings obtained on ≥2 separate occasions. 1 This lower threshold increased the prevalence of hypertension among U.S. adults from 32% to 46%, though most newly classified individuals require only lifestyle modification rather than immediate pharmacotherapy. 1, 2

Proper Blood Pressure Measurement Technique

Accurate measurement requires the patient to be seated with back support for >5 minutes, avoid caffeine/exercise/smoking for ≥30 minutes beforehand, have an empty bladder, use an appropriately sized cuff (covering ≥80% of arm circumference), keep the arm at heart level, and obtain 2–3 readings 1–2 minutes apart, averaging the last two. 3 Automated oscillometric devices that take repeated measurements without a provider present reduce the white-coat effect. 3

Screening Frequency

All adults ≥18 years should be screened for hypertension using office blood pressure measurement. 4 The U.S. Preventive Services Task Force concludes with high certainty that screening has substantial net benefit (Grade A recommendation). 4

Confirmation of Diagnosis with Out-of-Office Monitoring

Before initiating antihypertensive medication, confirm the diagnosis with out-of-office blood pressure monitoring—either home BP monitoring or 24-hour ambulatory BP monitoring—to exclude white-coat hypertension. 1, 5, 4

• White-coat hypertension accounts for 20–30% of apparent cases and carries cardiovascular risk similar to controlled hypertension. 3
• Home BP target is <135/85 mm Hg (corresponding to office <130/80 mm Hg). 3
• Approximately 93% of U.S. adults not on medication with office BP ≥130/80 mm Hg meet criteria for out-of-office monitoring to screen for white-coat hypertension. 6
• For patients with office BP <130/80 mm Hg but target organ damage or high cardiovascular risk, screen for masked hypertension with home monitoring; masked uncontrolled hypertension carries a two-fold higher mortality risk. 3, 6

Lifestyle Modifications (Foundational Therapy)

All individuals with BP ≥120/70 mm Hg should adopt comprehensive lifestyle measures before or alongside drug therapy. 2

• Sodium restriction: Limit intake to <2,400 mg/day, ideally <1,500 mg/day 3
• Weight loss: For overweight/obese patients (BMI ≥30 kg/m²), weight reduction provides robust BP lowering 3
• DASH diet: The Dietary Approaches to Stop Hypertension diet is the most effective dietary modification 7, 5
• Regular aerobic exercise: Recommended for all hypertensive adults 3
• Alcohol moderation: Limit to ≤2 drinks/day for men and ≤1 drink/day for women; reducing intake by 50% in those drinking ≥3 drinks/day lowers SBP/DBP by ≈5.5/4.0 mm Hg 3
• Smoking cessation: Independently reduces cardiovascular events and mortality 2

When to Initiate Pharmacologic Therapy

Stage 1 hypertension (130–139/80–89 mm Hg): Initiate antihypertensive medication when the patient has established atherosclerotic cardiovascular disease or when 10-year ASCVD risk calculated with the ACC/AHA Pooled Cohort Equations is ≥10%. 1, 2 Virtually all adults ≥70 years and most ≥65 years have 10-year ASCVD risk ≥10% and therefore meet the threshold for treatment at Stage 1 levels. 2

Stage 2 hypertension (≥140/90 mm Hg): Begin lifestyle measures and pharmacologic treatment simultaneously; do not delay therapy beyond 3 months to prevent therapeutic inertia. 2

First-Line Pharmacologic Agents

The four endorsed first-line drug classes are thiazide/thiazide-like diuretics, ACE inhibitors, angiotensin-receptor blockers (ARBs), and long-acting dihydropyridine calcium-channel blockers (CCBs). 2 All provide comparable blood pressure reductions of approximately 9/5 mm Hg (office) and 5/3 mm Hg (ambulatory) when used as monotherapy. 2

Optimal First-Line Choice for General Population

Thiazide-like diuretics (chlorthalidone 12.5–25 mg once daily or indapamide) are the optimal first-line agents for uncomplicated hypertension because they provide the strongest cardiovascular outcome evidence. 2 In the ALLHAT trial of >50,000 participants, chlorthalidone reduced heart-failure incidence by 38% compared with amlodipine and stroke incidence by 15% compared with lisinopril. 2 Chlorthalidone is preferred over hydrochlorothiazide because it provides superior 24-hour BP control due to its 40–60 hour half-life. 2, 3

Monotherapy vs. Combination Strategy

• Stage 1 hypertension: Start with single-agent monotherapy and titrate upward before adding a second agent from a different class. 2
• Stage 2 hypertension (≥140/90 mm Hg or >20/10 mm Hg above goal): Begin with a two-drug combination from different first-line classes, preferably as a single-pill formulation to improve adherence. 1, 2

Preferred Two-Drug Combinations

• RAS blocker (ACE inhibitor or ARB) + thiazide-like diuretic 2
• RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB 2

Single-pill combinations markedly improve medication adherence and persistence compared with separate pills. 2 Approximately 25% of patients never fill the initial prescription and only 20% achieve high adherence without such strategies. 3

Medication Selection Based on Comorbidities

Black Patients Without Heart Failure or CKD

Initiate therapy with a thiazide diuretic or calcium-channel blocker; ACE inhibitors and ARBs are less effective for stroke and heart-failure prevention in this group. 2 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 do not provide additional cardiovascular advantage. 2

Diabetes Mellitus

Prefer an ACE inhibitor or ARB as initial therapy to protect renal function, especially when albuminuria ≥300 mg/day is present. 2, 3 Target BP <130/80 mm Hg. 2

Chronic Kidney Disease (Stage 3+ or Albuminuria)

ACE inhibitor or ARB is first-line to decelerate eGFR decline and reduce proteinuria. 2 Thiazide diuretics remain effective even when eGFR <30 mL/min/1.73 m² and should not be avoided solely because of reduced kidney function; however, loop diuretics should be used when eGFR <30 mL/min. 2, 3

Post-Myocardial Infarction or Stable Ischemic Heart Disease

Combine a β-blocker with an ACE inhibitor or ARB as foundational therapy. 1, 2 If angina persists and BP remains uncontrolled, add a dihydropyridine CCB (e.g., amlodipine). 2 Target BP <130/80 mm Hg. 2 β-blockers should be continued for at least 3 years after MI; extending therapy beyond 3 years is reasonable for long-term hypertension control. 1

Heart Failure with Reduced Ejection Fraction

Use a three-drug regimen comprising an ACE inhibitor or ARB, a β-blocker, and a diuretic. 1, 2

Pregnancy

Women who become pregnant while hypertensive must be switched immediately to methyldopa, extended-release nifedipine, or labetalol; ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated due to fetal toxicity. 2, 8

Blood Pressure Treatment Targets

For most adults with confirmed hypertension, aim for BP <130/80 mm Hg. 1, 2 This target applies to:

• General adult population <65 years 2
• Adults with diabetes mellitus 2
• Adults with chronic kidney disease 2
• Adults with stable ischemic heart disease 2
• Adults with prior stroke or TIA (Class IIa recommendation) 2

For non-institutionalized, ambulatory adults ≥65 years with average systolic ≥130 mm Hg, the target systolic pressure is <130 mm Hg if tolerated. 1, 2 The 2024 ESC guideline recommends an optimal range of 120–129 mm Hg systolic / 70–79 mm Hg diastolic for most adults. 2

Diastolic Blood Pressure Considerations

In high-risk patients, diastolic pressure should not be lowered below 60–70 mm Hg; the optimal diastolic range is 70–79 mm Hg. 2 Excessive diastolic reduction may increase adverse cardiovascular events, particularly in patients with coronary artery disease where it may compromise coronary perfusion. 2

Agents Not Recommended as First-Line

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. 2 Reserve β-blockers for compelling indications (post-MI, stable angina, HFrEF, heart-rate control). 2

Alpha-blockers are not recommended as first-line agents because they are less effective for cardiovascular disease prevention than thiazide diuretics. 2 In ALLHAT, doxazosin was associated with an 80% higher rate of heart failure compared with chlorthalidone. 2

Contraindicated Combinations

Never combine an ACE inhibitor with an ARB (or add a direct renin inhibitor); dual renin-angiotensin system blockade increases the risk of hyperkalemia and acute kidney injury without providing additional cardiovascular benefit. 2

Follow-Up Schedule

After initiating or adjusting antihypertensive therapy, patients should be reviewed monthly until the blood pressure target is achieved. 1, 2 Once the target is reached, conduct follow-up every 3–5 months for maintenance. 1, 2 Dose adjustments should be spaced at least 4 weeks apart to allow full blood pressure response. 2

Laboratory Monitoring

Baseline evaluation should include serum creatinine with eGFR, potassium, fasting glucose or HbA1c, lipid panel, and urinalysis for albuminuria. 2, 3 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. 2, 3 An increase in serum creatinine of up to 50% above baseline or to 3 mg/dL (whichever is greater) is considered acceptable. 2

Out-of-office blood pressure 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, combined with team-based care and telehealth, improves blood pressure control. 1, 2

Management of Resistant Hypertension

Resistant hypertension is defined as BP ≥130/80 mm Hg despite adherence to ≥3 antihypertensive agents at optimal doses (including a diuretic), or BP <130/80 mm Hg requiring ≥4 agents. 2, 8

Systematic Approach to Resistant Hypertension

1. Confirm true resistance by excluding white-coat effect with out-of-office monitoring and assessing adherence; non-adherence is the leading cause of apparent resistant hypertension. 3

2. Identify contributing lifestyle factors: obesity, excess alcohol, high sodium intake, NSAIDs, decongestants, stimulants, oral contraceptives. 2, 3

3. Screen for secondary causes when clinical indications are present (Table 13 in source): abrupt onset or worsening of previously controlled hypertension, onset <30 years, accelerated/malignant hypertension, disproportionate target organ damage, unexplained hypokalemia. 1, 3 Common secondary causes include primary aldosteronism (8–20% prevalence in resistant hypertension), renovascular disease (5–34%), and renal parenchymal disease (1–2%). 3

4. Optimize diuretic therapy: Switch from hydrochlorothiazide to chlorthalidone or indapamide for superior 24-hour BP control; use loop diuretics when eGFR <30 mL/min. 2, 3

5. Add a mineralocorticoid-receptor antagonist (spironolactone 25–50 mg daily; if not tolerated, use eplerenone). 2, 3

6. Refer to a hypertension specialist if uncontrolled after 6 months of optimized therapy. 2

Special Population Considerations

Older Adults (≥85 years)

Continue BP-lowering treatment lifelong if well tolerated; asymptomatic orthostatic hypotension should not prompt withdrawal. 2 For older adults with high comorbidity burden and limited life expectancy, individualized clinical judgment and team-based risk-benefit assessment are reasonable. 1, 8

Young Adults (<40 years)

Perform comprehensive screening for secondary hypertension causes (renal artery stenosis, primary aldosteronism, pheochromocytoma, Cushing syndrome, coarctation). In obese young adults, begin with obstructive sleep apnea evaluation. 2

Common Pitfalls to Avoid

• Inadequate measurement technique leads to misclassification and inappropriate treatment decisions. 3
• Failing to confirm diagnosis with home or ambulatory monitoring results in overtreatment of white-coat hypertension (20–30% of apparent cases). 3
• Using hydrochlorothiazide instead of chlorthalidone or indapamide yields inferior blood pressure control. 3
• Delaying combination therapy in Stage 2 hypertension (≥140/90 mm Hg) increases cardiovascular risk. 2
• Excessive diastolic lowering below 60 mm Hg in high-risk patients may increase adverse cardiovascular events. 2
• Underestimating medication non-adherence; routinely assess missed doses, side effects, and cost barriers. 3
• Ignoring interfering substances (NSAIDs, decongestants, stimulants, oral contraceptives) that can raise blood pressure. 3