From the Guidelines
The latest hypertension guidelines recommend initiating treatment when blood pressure (BP) consistently exceeds 130/80 mmHg, with a target of below this threshold for most adults, as stated in the 2022 World Health Organization guideline executive summary 1.
Key Recommendations
- First-line medications include thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs, with specific dosages such as chlorthalidone 12.5-25mg daily or hydrochlorothiazide 12.5-50mg daily, amlodipine 2.5-10mg daily, lisinopril 10-40mg daily, or losartan 25-100mg daily.
- For Black patients, initial therapy should favor thiazide diuretics or calcium channel blockers, as recommended by the 2017 American College of Cardiology/American Heart Association guideline 1.
- Most patients will require two or more medications to achieve target BP, and fixed-dose combination pills improve adherence.
- Lifestyle modifications are essential for all patients, including:
- Sodium restriction (<2300mg/day)
- Regular physical activity (150 minutes/week)
- Weight management
- Limited alcohol consumption
- The DASH diet
Monitoring and Treatment Intensification
- BP should be monitored regularly, ideally with home measurements to avoid white-coat hypertension.
- Treatment should be intensified if targets aren't met within 3-6 months.
- For patients over 65, a slightly higher target of <140/90 mmHg may be appropriate, as suggested by the 2022 World Health Organization guideline executive summary 1.
Individualized Treatment Decisions
- Treatment decisions should be individualized based on comorbidities, medication tolerability, and patient preferences, taking into account the latest evidence from the 2022 World Health Organization guideline executive summary 1 and the 2017 American College of Cardiology/American Heart Association guideline 1.
From the Research
Diagnosis and Definition of Hypertension
- Hypertension is defined as persistent systolic blood pressure (SBP) at least 130 mm Hg or diastolic BP (DBP) at least 80 mm Hg 2
- It can also be defined as persistently elevated systolic blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) at least 90 mmHg 3
Lifestyle Modifications for Hypertension
- First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern that includes low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption 2
- Lifestyle changes should be continued even when blood pressure-lowering medications are prescribed 3
- Specific recommendations include maintaining a healthy body weight, increased levels of different types of physical activity, healthy eating and drinking, avoidance and cessation of smoking and alcohol use, management of stress and sleep levels 3
- Lifestyle interventions such as regular physical exercise, body weight management, and healthy dietary patterns can help prevent and treat hypertension 4
Dietary Approaches to Stop Hypertension (DASH) Diet
- The DASH diet is a potentially effective treatment for pre-hypertensive and hypertensive patients 5
- The modified DASH diet can reduce mean systolic and diastolic BP, waist circumference, and triglyceride concentration in hypertension patients 5
- The DASH diet can also be prescribed for many other chronic conditions and can help control metabolic risk factors such as body weight, BMI, and blood pressure 6
Pharmacologic Therapy for Hypertension
- First-line drug therapy for hypertension consists of a thiazide or thiazidelike diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker 2
- The decision to initiate antihypertensive medication should be based on the level of BP and the presence of high atherosclerotic CVD risk 2
- Randomized clinical trials have established the efficacy of BP lowering to reduce the risk of CVD morbidity and mortality 2