What are the current guidelines for diagnosing and managing hypertension in adults, including blood pressure thresholds, lifestyle modifications, first‑line pharmacologic agents, target blood pressure goals, and special considerations for patients of African ancestry, chronic kidney disease, diabetes, heart failure, and resistant hypertension?

Hypertension Management in Adults

Blood Pressure Classification and Diagnostic Thresholds

The 2017 ACC/AHA guideline defines hypertension as systolic ≥130 mmHg or diastolic ≥80 mmHg, while the 2024 European Society of Cardiology retains the traditional ≥140/90 mmHg threshold—this creates an international divergence that clinicians must navigate based on their practice setting. 1

ACC/AHA Classification

• Normal: <120/<80 mmHg 1
• Elevated: 120–129/<80 mmHg 1
• Stage 1 Hypertension: 130–139/80–89 mmHg 1
• Stage 2 Hypertension: ≥140/≥90 mmHg 1

Diagnostic Confirmation Requirements

• Diagnosis requires the average of ≥2 readings taken on ≥2 separate occasions using proper technique (seated, feet flat, back supported, arm at heart level after 5 minutes of quiet rest) 1, 2
• Before initiating medication, confirm the diagnosis with out-of-office monitoring (home BP ≥135/85 mmHg or 24-hour ambulatory ≥130/80 mmHg) to exclude white-coat hypertension, which affects 30% of CKD patients 1, 3
• Common measurement errors that falsely elevate readings include incorrect cuff size, cuff over clothing, unsupported arm, full bladder, conversation during measurement, and crossed or hanging legs 1

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Blood Pressure Treatment Targets

For most adults with hypertension, the target is <130/80 mmHg based on ACC/AHA guidelines, which provide the strongest cardiovascular outcome data. 1, 4

Population-Specific Targets

• General adult population <65 years: <130/80 mmHg (Class I, Level A) 1
• Adults ≥65 years (ambulatory, non-institutionalized): Systolic <130 mmHg if tolerated 1
• Diabetes mellitus: <130/80 mmHg 1, 2
• Chronic kidney disease: <130/80 mmHg 1, 2
• Stable ischemic heart disease: <130/80 mmHg 1
• Post-stroke/TIA: <130/80 mmHg may be reasonable 1

Critical Diastolic Consideration

• In high-risk patients, do not lower diastolic pressure below 60–70 mmHg; the optimal diastolic range is 70–79 mmHg to avoid compromising coronary perfusion 1

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Lifestyle Modifications

All individuals with BP ≥120/70 mmHg should adopt comprehensive lifestyle measures before or alongside pharmacologic therapy. 1

Evidence-Based Interventions

• Weight management: Target BMI <25 kg/m² 1
• DASH dietary pattern: Rich in fruits, vegetables, low-fat dairy, low in saturated fat 2
• Sodium restriction: <2 g/day (especially critical in CKD where sodium retention drives resistance) 5
• Potassium supplementation: 3.5–5 g/day unless contraindicated 1
• Regular aerobic activity: 150 minutes/week of moderate-intensity exercise 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1
• Smoking cessation: Independently reduces cardiovascular events and mortality 1

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When to Initiate Pharmacologic Therapy

Stage 1 Hypertension (130–139/80–89 mmHg)

Begin antihypertensive medication when the patient has established ASCVD OR 10-year ASCVD risk ≥10% (ACC/AHA Pooled Cohort Equations). 1, 6

• Virtually all adults ≥70 years and most ≥65 years meet the ≥10% risk threshold and therefore qualify for treatment at Stage 1 levels 1
• For patients with diabetes, CKD, or hypertension-mediated organ damage, initiate therapy even if 10-year risk is 5–10% 1

Stage 2 Hypertension (≥140/≥90 mmHg)

Start lifestyle measures AND pharmacologic therapy simultaneously; do not delay treatment beyond 3 months. 1, 6

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First-Line Pharmacologic Agents

The four first-line drug classes are thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, and long-acting dihydropyridine calcium-channel blockers—all provide comparable BP reductions of approximately 9/5 mmHg (office) and 5/3 mmHg (ambulatory) as monotherapy. 7, 1

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

Chlorthalidone 12.5–25 mg once daily is the optimal first-line agent for uncomplicated hypertension, providing superior cardiovascular protection compared to other classes. 1

• In the ALLHAT trial (>50,000 participants), chlorthalidone reduced heart failure by 38% versus amlodipine and stroke by 15% versus lisinopril 1
• Chlorthalidone is preferred over hydrochlorothiazide due to its 40–60 hour half-life providing true 24-hour BP control 1
• Alternative first-line options include long-acting dihydropyridine CCBs (amlodipine 5–10 mg daily) or ACE inhibitors (lisinopril 10–40 mg daily), though these are less effective for heart failure prevention 1

Black Patients Without Heart Failure or CKD

Initiate therapy with a thiazide diuretic (chlorthalidone) OR a calcium-channel blocker; ACE inhibitors and ARBs are 30–36% less effective for stroke prevention in this population due to lower renin activity. 7, 1

• ARBs may be better tolerated than ACE inhibitors (less cough, angioedema) but confer no additional cardiovascular benefit 1

Diabetes Mellitus

Prefer an ACE inhibitor or ARB as initial therapy to protect renal function, especially when albuminuria ≥300 mg/day is present. 1, 2

• Target BP <130/80 mmHg 1, 2
• When initiating ACE inhibitors or ARBs, repeat serum creatinine, eGFR, and potassium within 1–2 weeks, after each dose increase, and annually thereafter 1, 2
• An increase in serum creatinine up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable 1

Chronic Kidney Disease (Stage 3+ or Albuminuria)

ACE inhibitor or ARB is first-line to decelerate eGFR decline and reduce proteinuria. 1, 5

• Target BP <130/80 mmHg 1
• Thiazide diuretics remain effective even when eGFR <30 mL/min/1.73 m² and should not be avoided solely because of reduced kidney function 1
• In CKD stage 4 with uncontrolled hypertension, chlorthalidone is effective and serves as an alternative therapeutic option 5

Post-Myocardial Infarction or Stable Ischemic Heart Disease

Combine a β-blocker with an ACE inhibitor or ARB as foundational therapy; if angina persists and BP remains uncontrolled, add a dihydropyridine CCB. 1

• β-blockers should be continued for ≥3 years post-MI, with longer duration reasonable for ongoing hypertension control 1
• Target BP <130/80 mmHg 1

Heart Failure with Reduced Ejection Fraction

Use a three-drug regimen: ACE inhibitor or ARB + β-blocker + diuretic. 1

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Monotherapy vs. Combination Therapy Strategy

Stage 1 Hypertension (130–139/80–89 mmHg)

Start with single-agent monotherapy (chlorthalidone 12.5 mg or amlodipine 5 mg) and titrate upward before adding a second agent from a different class. 1

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. 7, 1, 6

Preferred Two-Drug Combinations

1. ACE inhibitor or ARB + thiazide/thiazide-like diuretic (optimal for general population due to strongest cardiovascular outcome evidence for thiazides) 1, 6
2. ACE inhibitor or ARB + long-acting dihydropyridine CCB (equally endorsed, especially useful when thiazides are contraindicated) 1, 6

• Single-pill combinations markedly improve medication adherence and persistence compared to separate pills 1, 6
• Combination therapy using two submaximal doses from different classes yields larger BP reductions with fewer adverse effects than maximal dosing of a single agent 7

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Escalation to Triple Therapy

If BP remains ≥140/90 mmHg after 3 months on a two-drug combination at optimal doses, add a third agent to create the standard triple regimen: ACE inhibitor or ARB + CCB + thiazide diuretic, preferably as a single-pill combination. 1, 6

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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. 7, 1

• Reserve for compelling indications: angina, post-MI, heart failure with reduced ejection fraction, or atrial fibrillation requiring rate control 1

α-Blockers

Not first-line because they are less effective for cardiovascular disease prevention than thiazide diuretics. 1

• In ALLHAT, doxazosin was associated with an 80% higher rate of heart failure compared to chlorthalidone 1

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Monitoring and Follow-Up

After initiating or adjusting antihypertensive therapy, review patients monthly until the BP target is achieved, then every 3–5 months for maintenance. 7, 1, 6

Laboratory Monitoring

• Baseline: Serum creatinine, eGFR, potassium, fasting glucose or HbA1c, lipid panel, urine albumin 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 1, 2
• Dose adjustments should be spaced ≥4 weeks apart to allow full BP response 1

Out-of-Office Monitoring

Home or ambulatory BP monitoring is essential to assess treatment response, detect white-coat effect, and identify masked uncontrolled hypertension. 1

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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. Confirm true resistance by excluding white-coat effect with out-of-office monitoring and assessing adherence (non-adherence is the most common cause of apparent resistance) 1, 6, 3
2. Identify contributing lifestyle factors: Obesity, excess alcohol, high sodium intake (especially critical in CKD where sodium retention drives resistance), NSAIDs, obstructive sleep apnea 1, 5
3. Screen for secondary causes: Primary aldosteronism, CKD, renal artery stenosis, pheochromocytoma, obstructive sleep apnea 1
4. Optimize diuretic therapy: Use loop diuretics in CKD; in CKD stage 4, chlorthalidone is effective for treatment-resistant hypertension 1, 5
5. Add a mineralocorticoid-receptor antagonist (e.g., spironolactone 25–50 mg daily); however, the risk of hyperkalemia restricts broad utilization in moderate-to-advanced CKD 1, 5
6. Refer to a hypertension specialist if uncontrolled after 6 months 1

CKD-Specific Considerations

• Patients with CKD have 2–3 times higher risk of developing resistant hypertension 8
• Up to half of CKD patients meet resistant hypertension criteria using the 2017 ACC/AHA target BP <130/80 mmHg 8
• Excess sodium retention in extracellular and tissue compartments remains the cornerstone cause of treatment resistance in CKD 5, 8
• Chlorthalidone can mitigate the risk of hyperkalemia to enable concomitant use of spironolactone, but this combination requires careful monitoring of BP and kidney function 5

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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

• Initiate treatment when confirmed office BP ≥140/90 mmHg; target BP <140/90 mmHg but avoid diastolic <80 mmHg 1

Older Adults (≥85 Years)

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

• For patients with high comorbidity burden or limited life expectancy, individualized clinical judgment and team-based risk-benefit assessment are reasonable 1

Young Adults (<40 Years)

Perform comprehensive screening for secondary hypertension causes: Renal artery stenosis, primary aldosteronism, pheochromocytoma, Cushing syndrome, coarctation 1

• In obese young adults, begin with obstructive sleep apnea evaluation 1

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Critical Pitfalls to Avoid

1. Delaying combination therapy in Stage 2 hypertension (≥140/90 mmHg) increases cardiovascular risk 1
2. Using β-blockers as first-line agents in patients >60 years without a compelling indication leads to inferior stroke prevention 7, 1
3. Excessive diastolic lowering below 60 mmHg in high-risk patients may increase adverse cardiovascular events 1
4. Combining an ACE inhibitor with an ARB (or adding a direct renin inhibitor) should be avoided due to lack of benefit and higher adverse-event risk (hyperkalemia, acute kidney injury) 1, 6
5. Continuing ACE inhibitors or ARBs during pregnancy is contraindicated because of fetal toxicity 1
6. Failing to employ out-of-office BP monitoring can miss white-coat (30% prevalence in CKD) or masked hypertension, compromising management 1, 3
7. Assuming treatment failure before confirming medication adherence, as non-adherence is the most common cause of apparent resistance 6