What are the current guideline recommendations for initiating and managing hypertension treatment in adults, including blood pressure targets, lifestyle modifications, first‑line medication choices, and follow‑up monitoring?

Management of Hypertension: Current Guideline Recommendations

Blood Pressure Diagnostic Thresholds

The 2017 ACC/AHA guideline defines hypertension as systolic ≥130 mmHg or diastolic ≥80 mmHg, while the 2022 WHO guideline retains the traditional threshold of ≥140/90 mmHg, creating an international divergence in diagnostic criteria. 1, 2

• Stage 1 hypertension: 130–139/80–89 mmHg (ACC/AHA definition) 1, 2
• Stage 2 hypertension: ≥140/90 mmHg (both ACC/AHA and WHO) 1, 2
• Diagnosis requires an average of ≥2 readings on ≥2 separate occasions, confirmed with out-of-office monitoring (home or 24-hour ambulatory) to exclude white-coat hypertension 1, 2

Blood Pressure Treatment Targets

For adults with confirmed hypertension and known cardiovascular disease or 10-year ASCVD risk ≥10%, the target is <130/80 mmHg. 1, 2, 3

• General adult population <65 years: <130/80 mmHg 1, 2, 3
• Non-institutionalized adults ≥65 years: systolic <130 mmHg if tolerated 1, 2
• Patients with diabetes mellitus: <130/80 mmHg 1, 2, 3
• Patients with chronic kidney disease: <130/80 mmHg 1, 2, 3
• Stable ischemic heart disease: <130/80 mmHg 1, 2
• WHO target for patients without comorbidities: <140/90 mmHg 1, 3
• Critical diastolic consideration: In high-risk patients, do not lower diastolic below 60–70 mmHg; optimal range is 70–79 mmHg 2

Lifestyle Modifications (Mandatory for All Patients)

All individuals with blood pressure ≥120/70 mmHg should adopt comprehensive lifestyle measures before or alongside drug therapy: 2, 4

• Sodium restriction to <1,500 mg/day 2, 4
• DASH dietary pattern (high in fruits, vegetables, whole grains, low-fat dairy) 2, 4
• Weight reduction to achieve BMI <25 kg/m² 2, 4
• Aerobic exercise 90–150 minutes per week 2, 4
• Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) 2, 4
• Potassium supplementation 3,500–5,000 mg/day when not contraindicated 2, 4
• Smoking cessation 2, 4

When to Initiate Pharmacologic Therapy

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

Begin antihypertensive medication when the patient has established atherosclerotic cardiovascular disease OR 10-year ASCVD risk ≥10% calculated with the ACC/AHA Pooled Cohort Equations. 1, 2, 3

• Virtually all adults ≥70 years and most ≥65 years meet the ≥10% ASCVD risk threshold and qualify for treatment at Stage 1 levels 2
• For patients without these criteria, implement intensive lifestyle modification for 3 months; add medication if BP remains ≥130/80 mmHg 2

Stage 2 Hypertension (≥140/90 mmHg)

Initiate lifestyle measures AND pharmacologic therapy simultaneously; do not delay treatment beyond 3 months. 1, 2, 3

First-Line Pharmacologic Agents

Four drug classes are endorsed as first-line therapy: thiazide or thiazide-like diuretics, ACE inhibitors, angiotensin-receptor blockers (ARBs), and long-acting dihydropyridine calcium-channel blockers (CCBs). 1, 2, 3

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

Thiazide diuretics—especially chlorthalidone—are the optimal first-line agents, with the strongest cardiovascular outcome evidence from trials involving >50,000 participants. 2, 3

• Chlorthalidone demonstrated superior stroke prevention versus lisinopril and superior heart-failure prevention versus amlodipine in the ALLHAT trial 2
• All four first-line classes produce comparable office BP reductions of approximately 9/5 mmHg 2

Black Patients Without Heart Failure or CKD

Initiate therapy with a thiazide diuretic or calcium-channel blocker; ACE inhibitors and ARBs are 30–36% less effective for stroke prevention in this population due to lower renin activity. 1, 2, 3, 5

• ARBs may cause less cough and angioedema than ACE inhibitors but provide no additional cardiovascular benefit 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. 1, 2, 3

• Target BP <130/80 mmHg 1, 2, 3

Patients with Chronic Kidney Disease (Stage 3+ or Albuminuria)

An ACE inhibitor or ARB is first-line to decelerate eGFR decline and reduce proteinuria. 1, 2, 3

• Target BP <130/80 mmHg 1, 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 1, 2
• β-blockers should be continued for ≥3 years post-MI 1, 2
• Target BP <130/80 mmHg 1, 2

Heart Failure with Reduced Ejection Fraction

Use a three-drug regimen: ACE inhibitor or ARB + β-blocker + diuretic. 1, 2

Monotherapy vs. Combination Therapy Strategy

Stage 1 Hypertension

Start with single-agent monotherapy and titrate upward before adding a second agent from a different class. 1, 2, 3

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, 2, 3

• Preferred combinations:
  1. Thiazide diuretic + (ACE inhibitor or ARB) 1, 2, 3
  2. CCB + (ACE inhibitor or ARB) 1, 2, 3
• Single-pill combinations markedly improve medication adherence and persistence 1, 2
• Combination therapy using two submaximal doses yields larger BP reductions with fewer adverse effects than maximal dosing of a single agent 2

Triple Therapy Escalation

If BP remains uncontrolled after 3 months on a two-drug regimen, escalate to triple therapy (ACE inhibitor/ARB + CCB + thiazide diuretic), preferably as a single-pill combination. 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. 1, 2, 3

• Reserve β-blockers for compelling indications: post-MI, stable angina, HFrEF, or heart-rate control 2

Alpha-blockers are not first-line because they are less effective for cardiovascular disease prevention than thiazide diuretics. 2, 3

Critical Contraindications

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

Follow-Up and Monitoring

After initiating or adjusting antihypertensive therapy, review patients monthly until the BP target is achieved, then every 3–5 months for maintenance. 1, 2, 3

• Dose adjustments should be spaced at least 4 weeks apart to allow full BP response 2
• Out-of-office BP monitoring (home or ambulatory) is essential to assess treatment response, detect white-coat effect, and identify masked uncontrolled hypertension 1, 2

Laboratory Monitoring

• Baseline: serum creatinine, eGFR, potassium, fasting glucose, lipid panel 2
• 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
• An increase in serum creatinine up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable 2

Special Population Considerations

Pregnancy

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

Older Adults (≥85 Years)

Continue BP-lowering treatment lifelong if well tolerated; asymptomatic orthostatic hypotension alone should not prompt drug withdrawal. 2

• For older adults with high comorbidity burden or limited life expectancy, individualized clinical judgment and team-based risk-benefit assessment are reasonable 2

Young Adults (<40 Years)

Perform comprehensive screening for secondary hypertension causes: renal artery stenosis, primary aldosteronism, pheochromocytoma, Cushing syndrome, coarctation. 2

• In obese young adults, begin with obstructive sleep apnea evaluation 2

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. 2

Systematic Approach:

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

Common Pitfalls to Avoid

• Delaying combination therapy in Stage 2 hypertension (≥140/90 mmHg) increases cardiovascular risk 2
• Using β-blockers as first-line in patients >60 years without compelling indication leads to inferior stroke prevention 1, 2
• Excessive diastolic lowering below 60 mmHg in high-risk patients may increase adverse cardiovascular events 2
• Failing to employ out-of-office BP monitoring can miss white-coat or masked hypertension, compromising management 1, 2
• Relying on a single office measurement for diagnosis; improper technique can falsely raise readings by 10–30 mmHg 2
• Combining ACE inhibitor with ARB raises hyperkalemia and AKI risk without benefit 1, 2
• Continuing ACE inhibitors or ARBs during pregnancy is contraindicated due to fetal toxicity 2