What are the recommended guidelines for diagnosing and managing hypertension in adults, including blood pressure thresholds, lifestyle modifications, and first‑line pharmacologic therapy?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: February 26, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Hypertension: Diagnosis and Management in Adults

Blood Pressure Diagnostic Thresholds

Hypertension is defined as systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg based on the 2017 ACC/AHA guideline, which lowered the threshold from the traditional 140/90 mmHg. 1, 2

Blood Pressure Categories (ACC/AHA Classification)

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

Diagnostic Confirmation Requirements

  • The diagnosis requires an average of ≥2 readings obtained on ≥2 separate occasions using proper technique: seated with back supported, feet flat on floor, arm at heart level after 5 minutes of quiet rest. 1, 3, 4
  • Out-of-office blood pressure monitoring (home or 24-hour ambulatory) must be used to confirm the diagnosis before initiating medication to exclude white-coat hypertension and identify masked hypertension. 1, 3, 2, 5
  • Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms true hypertension when office readings are elevated. 1

Blood Pressure Treatment Targets

For most adults with hypertension, the target blood pressure is <130/80 mmHg. 1, 2, 6

Population-Specific Targets

  • General adult population (<65 years): <130/80 mmHg 1
  • Adults ≥65 years (ambulatory, community-dwelling): Systolic <130 mmHg if tolerated 1, 2
  • Diabetes mellitus: <130/80 mmHg 1, 3
  • Chronic kidney disease (stage 3+ or albuminuria ≥300 mg/day): <130/80 mmHg 1, 3
  • Stable ischemic heart disease or post-MI: <130/80 mmHg 1
  • High-risk patients: Avoid lowering diastolic pressure below 60–70 mmHg; optimal diastolic range is 70–79 mmHg 1

Lifestyle Modifications (First-Line for All)

All individuals with blood pressure ≥120/70 mmHg should adopt comprehensive lifestyle measures before or alongside pharmacologic therapy. 1, 3, 6

Evidence-Based Lifestyle Interventions

  • Sodium restriction to <1,500 mg/day 1
  • DASH dietary pattern (high in fruits, vegetables, whole grains, low-fat dairy, low in saturated fat) 1, 3, 6
  • Weight reduction to achieve BMI <25 kg/m² 1, 6
  • Aerobic exercise 90–150 minutes per week 1, 6
  • Potassium supplementation 3,500–5,000 mg/day when not contraindicated 1, 6
  • Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) 1, 6
  • Smoking cessation 1, 6

When to Initiate Pharmacologic Therapy

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

Begin antihypertensive medication when the patient has established cardiovascular disease OR a 10-year ASCVD risk ≥10% calculated with the ACC/AHA Pooled Cohort Equations. 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. 1
  • If 10-year ASCVD risk is <10% and no high-risk conditions exist, continue lifestyle modification alone and reassess annually. 1

Stage 2 Hypertension (≥140/≥90 mmHg)

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

  • Start with a two-drug combination from different first-line classes, preferably as a single-pill formulation. 1, 2

High-Risk Conditions Requiring Earlier Treatment

Medication is indicated regardless of risk score when any of the following are present:

  • Established cardiovascular disease 1
  • Diabetes mellitus 1, 3
  • Chronic kidney disease (stage 3+ or albuminuria ≥300 mg/day) 1, 3
  • Hypertension-mediated organ damage (left ventricular hypertrophy, retinopathy, microalbuminuria) 1
  • Familial hypercholesterolemia 1

First-Line Pharmacologic Therapy

The four first-line drug classes are thiazide/thiazide-like diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs), and long-acting dihydropyridine calcium-channel blockers (CCBs). 1, 6, 7, 5

Optimal First-Line Agent for General Population

Chlorthalidone 12.5–25 mg once daily is the optimal first-line agent for uncomplicated hypertension because it provides superior cardiovascular outcomes demonstrated in the ALLHAT trial of >50,000 participants. 1, 8

  • In ALLHAT, chlorthalidone reduced heart failure incidence by 38% compared with amlodipine and stroke incidence by 15% compared with lisinopril. 1
  • Chlorthalidone is preferred over hydrochlorothiazide due to its 40–60 hour half-life providing 24-hour BP control and stronger outcome evidence. 1, 3
  • Start at 12.5 mg daily, titrate to 25 mg after 4 weeks if needed; doses >25 mg increase metabolic side effects without additional BP benefit. 1

Population-Specific First-Line Choices

Black Patients Without Heart Failure or CKD

Initiate therapy with a thiazide diuretic (chlorthalidone preferred) or calcium-channel blocker. 1

  • ACE inhibitors and ARBs are 30–36% less effective for stroke prevention in Black patients due to lower renin activity. 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. 1, 3

  • When albuminuria ≥300 mg/day is present, ACE inhibitor or ARB is mandatory to slow kidney disease progression. 1

Chronic Kidney Disease (Stage 3+ or Albuminuria)

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

Post-Myocardial Infarction or Stable Ischemic Heart Disease

Combine a β-blocker with an ACE inhibitor or ARB as foundational therapy. 1

  • β-blockers should be continued for ≥3 years post-MI; extending therapy beyond 3 years is reasonable for ongoing hypertension control. 1
  • If angina persists and BP remains uncontrolled, add a dihydropyridine CCB (e.g., amlodipine). 1

Heart Failure with Reduced Ejection Fraction

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

Combination Therapy Strategy

Stage 1 Hypertension

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

  • Reassess monthly until BP <130/80 mmHg is achieved. 1

Stage 2 Hypertension

Begin with a two-drug combination from different first-line classes, preferably as a single-pill formulation. 1, 2

Preferred Two-Drug Combinations

  • Thiazide diuretic + (ACE inhibitor or ARB) 1

  • Calcium-channel blocker + (ACE inhibitor or ARB) 1

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

  • Combination therapy using two submaximal doses from different classes yields larger BP reductions with fewer adverse effects than maximal dosing of a single agent. 1

Escalation to Triple Therapy

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. 1

Agents NOT Recommended as First-Line

β-Blockers

β-blockers should not be used as first-line therapy in uncomplicated hypertension, especially in patients >60 years, because they are ≈36% less effective than CCBs and ≈30% less effective than thiazides for stroke prevention. 1

  • Reserve β-blockers for compelling indications: post-MI, heart failure with reduced ejection fraction, angina, or heart rate control. 1

Alpha-Blockers

Alpha-blockers are 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 with chlorthalidone. 1

Monitoring and Follow-Up

Visit Schedule

  • After initiating or adjusting therapy, review patients monthly until the BP target is achieved, then every 3–5 months for maintenance. 1, 2
  • Dose adjustments should be spaced ≥4 weeks apart to allow full BP response. 1

Laboratory Monitoring

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

Out-of-Office Monitoring

Systematic use of home BP monitoring is essential to assess treatment response, detect white-coat effect, and identify masked uncontrolled hypertension. 1, 2

Resistant Hypertension

Resistant hypertension is 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, 2

Systematic Approach

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

Special Populations

Pregnancy

Women who become pregnant while hypertensive must be switched immediately to methyldopa, extended-release nifedipine, or labetalol. 1, 2

  • ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated in pregnancy due to fetal toxicity. 1, 2

Older Adults (≥85 Years)

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

  • For older adults with high comorbidity burden or limited life expectancy, individualized clinical judgment and team-based risk-benefit assessment are reasonable. 1, 2

Critical Pitfalls to Avoid

  • Delaying combination therapy in Stage 2 hypertension (≥140/90 mmHg) increases cardiovascular risk. 1
  • Using β-blockers as first-line agents in patients >60 years without a compelling indication leads to inferior stroke prevention. 1
  • Excessive diastolic lowering below 60 mmHg in high-risk patients may increase adverse cardiovascular events. 1
  • 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
  • Continuing ACE inhibitors or ARBs during pregnancy is contraindicated because of fetal toxicity. 1, 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. 1
  • Initiating medication immediately in low-risk individuals with BP 130–139/70–89 mmHg leads to overtreatment. 1

References

1
Guideline

Hypertension Diagnosis, Treatment Targets, and Management in Adults

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

2017 ACC/AHA Hypertension Guidelines: Key Updates

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Hypertension Classification, Diagnosis, and Management Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Research

Definition of hypertension: the impact of number of visits for blood pressure measurement.

Revista portuguesa de cardiologia : orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology, 2009

5
Research

Arterial hypertension.

Lancet (London, England), 2021

7
Research

Hypertension.

Nature reviews. Disease primers, 2018

8
Research

Systemic hypertension.

Current problems in cardiology, 2007

Related Questions

How to manage a blood pressure reading of 162?
How should an asymptomatic adult with elevated blood pressure be evaluated and treated?
How should I manage a 30-year-old woman with a blood pressure of 146/90 mm Hg (stage 2 hypertension) and no prior hypertension diagnosis?
How is hypertension managed in a pediatric patient?
What is the best approach to treating hypertension?
What is the appropriate cefalexin (Keflex) dosing for an otherwise healthy patient in their late 80s with normal renal function?
What are the common causes of acute pancreatitis?
What are the indications, dosing regimens, contraindications, precautions, and adverse effects of ondansetron for prevention and treatment of acute nausea and vomiting in adults and children?
Is a serum potassium of 5.7 mEq/L considered elevated (hyperkalemia) in an adult?
Should a patient who took multiple MDMA (ecstasy) tablets be somatically monitored after 6 hours?
What does a lighter shade of gray on a lumbar magnetic resonance imaging (MRI) indicate?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question