What are the current treatment guidelines for hypertension in adults, including blood pressure targets, first‑line medication classes, comorbidity‑specific choices, and recommended lifestyle measures?

Current Treatment Guidelines for Hypertension in Adults

Blood Pressure Diagnostic Thresholds

The ACC/AHA defines hypertension as blood pressure ≥130/80 mm Hg, while the European Society of Cardiology retains the traditional ≥140/90 mm Hg threshold. 1 This creates an international divergence in diagnostic criteria, with the ACC/AHA threshold increasing U.S. prevalence from 32% to 46% of adults. 1

• Stage 1 hypertension: 130–139/80–89 mm Hg (ACC/AHA) 1
• Stage 2 hypertension: ≥140/90 mm Hg 1
• Diagnosis must be confirmed with out-of-office monitoring (home or 24-hour ambulatory) to exclude white-coat hypertension before starting medication. 1

Blood Pressure Treatment Targets

For most adults, target blood pressure is <130/80 mm Hg. 1 This applies across the general population, patients with diabetes, chronic kidney disease, and stable ischemic heart disease. 1

• Adults <65 years with CVD or 10-year ASCVD risk ≥10%: <130/80 mm Hg 1
• Non-institutionalized adults ≥65 years: systolic <130 mm Hg if tolerated 1
• Critical diastolic floor: Do not lower diastolic below 60–70 mm Hg in high-risk patients; optimal diastolic range is 70–79 mm Hg 1

When to Initiate Pharmacologic Therapy

Stage 2 hypertension (≥140/90 mm Hg) requires immediate pharmacologic treatment alongside lifestyle modification. 1 Do not delay beyond 3 months to prevent therapeutic inertia. 1

Stage 1 hypertension (130–139/80–89 mm Hg) requires medication when:

• 10-year ASCVD risk ≥10% (calculated with ACC/AHA Pooled Cohort Equations) 1
• Established cardiovascular disease 1
• Diabetes mellitus 1
• Chronic kidney disease 1
• Hypertension-mediated organ damage 1

Virtually all adults ≥70 years and most ≥65 years meet the 10-year ASCVD risk ≥10% threshold and therefore qualify for treatment at Stage 1 levels. 1

First-Line Pharmacologic Agents

Four drug classes are endorsed as first-line therapy: thiazide/thiazide-like diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs), and long-acting dihydropyridine calcium channel blockers (CCBs). 1 All provide comparable blood pressure reductions of approximately 9/5 mm Hg (office) and 5/3 mm Hg (ambulatory) as monotherapy. 1

Optimal First-Line Choice for General Population

Thiazide-like diuretics—particularly chlorthalidone 12.5–25 mg daily—are the optimal first-line agent for uncomplicated hypertension because they have the strongest cardiovascular outcome evidence from trials enrolling >50,000 participants. 1 In the ALLHAT trial, chlorthalidone reduced heart failure incidence by 38% compared with amlodipine and stroke incidence by 15% compared with lisinopril. 1

Population-Specific First-Line Choices

Black patients without heart failure or CKD: Initiate with thiazide diuretic or CCB; ACE inhibitors and ARBs are 30–36% less effective for stroke prevention in this population due to lower renin activity. 1

Diabetes mellitus: Prefer ACE inhibitor or ARB as initial therapy to protect renal function. 1

Chronic kidney disease (stage 3+ or albuminuria ≥300 mg/day): ACE inhibitor or ARB is first-line to slow kidney disease progression. 1

Post-myocardial infarction or stable ischemic heart disease: Combine β-blocker with ACE inhibitor or ARB; continue β-blocker for ≥3 years post-MI. 1

Heart failure with reduced ejection fraction: Use three-drug regimen comprising ACE inhibitor or ARB + β-blocker + diuretic. 1

Monotherapy vs. Combination Strategy

Stage 1 hypertension: Start with single-agent monotherapy and titrate upward before adding a second agent from a different class. 1

Stage 2 hypertension (≥140/90 mm Hg or >20/10 mm Hg above goal): Begin with two-drug combination from different first-line classes, preferably as a single-pill formulation to improve adherence. 1 Delaying combination therapy in Stage 2 hypertension increases cardiovascular risk. 1

Preferred Two-Drug Combinations

• ACE inhibitor or ARB + thiazide diuretic 1
• ACE inhibitor or ARB + long-acting dihydropyridine CCB 1

Single-pill combinations markedly improve medication adherence and persistence compared with separate pills. 1

Escalation to Triple Therapy

If blood pressure remains uncontrolled after 3 months on two drugs, escalate to triple therapy: ACE inhibitor or ARB + CCB + thiazide diuretic, preferably as a single-pill combination. 1

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 approximately 36% less effective than CCBs and 30% less effective than thiazides for stroke prevention. 1

Alpha-blockers are not first-line agents because they are less effective for cardiovascular disease prevention than thiazide diuretics. 1

Clonidine should never be used as initial therapy due to significant CNS adverse effects, especially in older adults; it is reserved only for resistant hypertension after failure of first-line agents. 2

Lifestyle Modifications

All individuals with blood pressure ≥120/70 mm Hg should adopt comprehensive lifestyle measures before or alongside drug therapy: 1

• Sodium restriction to <2,300 mg/day 3
• Weight reduction if BMI >25 kg/m² 3
• DASH dietary pattern 1
• Physical activity ≥150 minutes/week of moderate-to-vigorous aerobic exercise 3
• Alcohol limitation to <14 units/week for men and <8 units/week for women 3
• Smoking cessation 1

Monitoring and Follow-Up

After initiating or adjusting therapy, review patients monthly until blood pressure target is achieved, then every 3–5 months for maintenance. 1 Dose adjustments should be spaced at least 4 weeks apart to allow full blood pressure response. 1

Baseline laboratory evaluation: serum creatinine, eGFR, potassium, fasting glucose, lipid panel 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 An increase in serum creatinine up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable. 1

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

Special Population Considerations

Pregnancy

Women who become pregnant while hypertensive should be switched to methyldopa, nifedipine, or labetalol. 1 ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated in pregnancy due to fetal toxicity. 1

Older Adults (≥65 years)

Non-institutionalized, ambulatory adults ≥65 years with systolic ≥130 mm Hg should be treated to systolic <130 mm Hg if tolerated. 1 Exercise caution when initiating combination therapy in those at risk for orthostatic hypotension. 1 For adults ≥85 years, continue blood pressure-lowering therapy lifelong if well tolerated; asymptomatic orthostatic hypotension alone should not prompt drug withdrawal. 1

Resistant Hypertension

Defined as blood pressure ≥130/80 mm Hg despite ≥3 antihypertensive agents at optimal doses (including a diuretic), or blood pressure <130/80 mm Hg requiring ≥4 agents. 1

Systematic approach:

1. Confirm true resistance by excluding white-coat effect with out-of-office monitoring and assessing adherence 1
2. Identify contributing lifestyle factors (obesity, excess alcohol, high sodium, NSAIDs) 1
3. Screen for secondary causes (primary aldosteronism, CKD, renal artery stenosis, pheochromocytoma, obstructive sleep apnea) 1
4. Optimize diuretic therapy, using loop diuretics in CKD 1
5. Add a mineralocorticoid-receptor antagonist (e.g., spironolactone) 1
6. Refer to a hypertension specialist if uncontrolled after 6 months 1

Critical Pitfalls to Avoid

• Never combine an ACE inhibitor with an ARB (or add a direct renin inhibitor): This increases risk of hyperkalemia and acute kidney injury without added cardiovascular benefit. 1
• Do not delay combination therapy in Stage 2 hypertension (≥140/90 mm Hg): This increases cardiovascular risk. 1
• Avoid excessive diastolic lowering below 60 mm Hg in high-risk patients: This may increase adverse cardiovascular events. 1
• Do not use β-blockers as first-line in patients >60 years without compelling indication: They provide inferior stroke prevention. 1
• Never prescribe clonidine PRN for blood pressure control: This creates life-threatening rebound hypertension risk. 2
• Do not abruptly discontinue clonidine if a patient is already taking it: Taper gradually to prevent hypertensive crisis. 2
• Failing to employ out-of-office blood pressure monitoring can miss white-coat or masked hypertension, compromising management. 1