What are the current hypertension management guidelines for adult patients, presented as a table showing blood‑pressure categories, target blood pressure, lifestyle measures, first‑line drug class with dosing ranges, and preferred second‑line add‑on therapy?

Hypertension Management Guidelines

Blood Pressure Classification & Diagnostic Thresholds

The ACC/AHA defines hypertension as ≥130/80 mmHg, while the WHO and ESC retain the traditional ≥140/90 mmHg threshold. 1 For practical management, use the ACC/AHA classification:

Category	Systolic (mmHg)	Diastolic (mmHg)
Normal	<120	<80
Elevated	120–129	<80
Stage 1 Hypertension	130–139	80–89
Stage 2 Hypertension	≥140	≥90

1

• Diagnosis requires the average of ≥2 readings on ≥2 separate occasions, confirmed with out-of-office monitoring (home BP ≥135/85 mmHg or 24-hour ambulatory ≥130/80 mmHg) to exclude white-coat hypertension. 1, 2

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Blood Pressure Treatment Targets

Population	Target BP (mmHg)	Strength
General adults <65 years	<130/80	Class I, Level A
Adults ≥65 years (ambulatory, non-institutionalized)	Systolic <130	Class IIa
Established CVD or 10-year ASCVD risk ≥10%	<130/80	Class I, Level A
Diabetes mellitus	<130/80	Class I
Chronic kidney disease	<130/80	Class I
Stable ischemic heart disease	<130/80	Class I, Level A
Post-stroke/TIA	<130/80	Class IIa

1, 2, 3

Critical diastolic consideration: In high-risk patients, do not lower diastolic BP 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 Patients with BP ≥120/70 mmHg)

Intervention	Target	Expected BP Reduction
Weight loss	BMI <25 kg/m²	5–20 mmHg per 10 kg
DASH diet	High fruits, vegetables, low-fat dairy	8–14 mmHg
Sodium restriction	<1,500 mg/day	2–8 mmHg
Potassium supplementation	3,500–5,000 mg/day	4–5 mmHg
Aerobic exercise	90–150 min/week	4–9 mmHg
Alcohol moderation	≤2 drinks/day (men), ≤1 (women)	2–4 mmHg
Smoking cessation	Complete cessation	Reduces CVD events

1, 3

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When to Initiate Pharmacologic Therapy

BP Category	Clinical Scenario	Action
Stage 1 (130–139/80–89)	10-year ASCVD risk ≥10% OR established CVD	Start medication immediately
Stage 1 (130–139/80–89)	10-year ASCVD risk <10%, no CVD	Lifestyle modification × 3 months; add medication if BP remains ≥130/80
Stage 2 (≥140/90)	All patients	Start lifestyle AND medication simultaneously; do not delay >3 months

1, 4, 2

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First-Line Pharmacologic Therapy by Population

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

Chlorthalidone 12.5–25 mg once daily is the optimal first-line agent because ALLHAT trial data (>50,000 participants) demonstrated superior cardiovascular outcomes: 38% reduction in heart failure vs. amlodipine and 15% reduction in stroke vs. lisinopril. 1

Drug Class	Example & Dose Range	Key Evidence
Thiazide-like diuretic (preferred)	Chlorthalidone 12.5–25 mg daily	Strongest outcome data; superior for heart failure & stroke prevention [1]
ACE inhibitor	Lisinopril 10–40 mg daily	Effective but 15% less stroke prevention than chlorthalidone [1]
ARB	Losartan 50–100 mg daily	Similar to ACE-I; less cough/angioedema [1]
Long-acting CCB	Amlodipine 5–10 mg daily	Comparable outcomes except heart failure [1]

1, 3, 5

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Black Patients Without Heart Failure or CKD

Start with thiazide diuretic (chlorthalidone preferred) OR calcium-channel blocker because ACE inhibitors and ARBs are 30–36% less effective for stroke prevention in this population due to lower renin activity. 1, 2

Preferred First-Line	Dose Range
Chlorthalidone	12.5–25 mg daily
Amlodipine	5–10 mg daily

1

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Diabetes Mellitus

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

Drug Class	Example & Dose Range
ACE inhibitor	Enalapril 5–40 mg daily
ARB	Candesartan 8–32 mg daily

1

• Target BP: <130/80 mmHg 1
• Monitor creatinine, eGFR, and potassium within 1–2 weeks of initiation, after dose increases, and annually. 1

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Chronic Kidney Disease (Stage 3+ or Albuminuria)

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

Drug Class	Example & Dose Range
ACE inhibitor	Lisinopril 10–40 mg daily
ARB	Losartan 50–100 mg daily

1

• Target BP: <130/80 mmHg 1
• An increase in serum creatinine up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable. 1

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Post-Myocardial Infarction or Stable Ischemic Heart Disease

Combine β-blocker + ACE inhibitor or ARB as foundational therapy. 1, 2

Drug Class	Example & Dose Range
β-blocker	Metoprolol succinate 50–200 mg daily
ACE inhibitor	Lisinopril 10–40 mg daily
ARB (if ACE-I intolerant)	Losartan 50–100 mg daily

1

• If angina persists and BP remains uncontrolled, add a dihydropyridine CCB (e.g., amlodipine 5–10 mg daily). 1
• Continue β-blocker for ≥3 years post-MI; longer duration is reasonable for ongoing hypertension control. 1
• Target BP: <130/80 mmHg 1

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Heart Failure with Reduced Ejection Fraction

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

Drug Class	Example & Dose Range
ACE inhibitor	Enalapril 5–20 mg twice daily
β-blocker	Carvedilol 6.25–25 mg twice daily
Diuretic	Furosemide 20–80 mg daily (adjust to volume status)

1

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Monotherapy vs. Combination Strategy

BP Stage	Strategy	Rationale
Stage 1 (130–139/80–89)	Start single-agent monotherapy; titrate before adding second agent	Gradual escalation minimizes adverse effects [1,2]
Stage 2 (≥140/90 or >20/10 mmHg above goal)	Start two-drug combination from different classes, preferably as single-pill formulation	Faster BP control, improved adherence, superior cardiovascular outcomes [1,4,2]

1, 4, 2

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Preferred Two-Drug Combinations

For Stage 2 hypertension, initiate combination therapy immediately:

Combination	Example Regimen	Population
Thiazide + ACE-I/ARB (preferred for general population)	Chlorthalidone 12.5 mg + lisinopril 10 mg	Non-Black adults; strongest outcome data [1]
CCB + ACE-I/ARB	Amlodipine 5 mg + lisinopril 10 mg	When thiazides contraindicated or poorly tolerated [1]
Thiazide + CCB	Chlorthalidone 12.5 mg + amlodipine 5 mg	Black patients without HF or CKD [1]

1, 4

• Single-pill combinations markedly improve adherence and persistence. 1, 4

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Escalation to Triple Therapy

If BP remains ≥140/90 mmHg after 3 months on optimized two-drug therapy, add a third agent to create the standard triple regimen:

ACE inhibitor or ARB + CCB + thiazide diuretic (preferably as single-pill combination). 1, 4

Drug Class	Example & Dose Range
ACE-I or ARB	Lisinopril 20–40 mg daily
CCB	Amlodipine 5–10 mg daily
Thiazide-like diuretic	Chlorthalidone 12.5–25 mg daily

1, 4

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Agents NOT Recommended as First-Line

Drug Class	Reason to Avoid	Evidence
β-blockers (unless compelling indication)	≈36% less effective than CCBs and ≈30% less effective than thiazides for stroke prevention in patients >60 years	Class III [1,2]
α-blockers	Less effective for CVD prevention than thiazides; 80% higher heart failure rate in ALLHAT	Class III [1]
Loop diuretics	Reserved for heart failure or advanced CKD (eGFR <30); not proven for uncomplicated hypertension	Class III [1]

1, 2

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Contraindicated Combinations

NEVER combine ACE inhibitor + ARB (or add direct renin inhibitor) because dual RAS blockade increases hyperkalemia and acute kidney injury risk without added cardiovascular benefit. 1, 4, 2

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Monitoring & Follow-Up Schedule

Phase	Frequency	Actions
After initiating or adjusting therapy	Monthly until BP target achieved	Check BP, assess adherence, monitor for adverse effects [1,4,2]
Maintenance (at goal)	Every 3–5 months	Confirm BP control, reinforce lifestyle measures [1,4,2]
After starting ACE-I, ARB, or diuretic	1–2 weeks	Repeat creatinine, eGFR, potassium; then after dose increases and annually [1]

1, 4, 2

• Dose adjustments should be spaced ≥4 weeks apart to allow full BP response. 1
• Out-of-office BP monitoring (home or ambulatory) is essential to detect white-coat or masked hypertension. 1

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Special Population Considerations

Pregnancy

• Switch to methyldopa, extended-release nifedipine, or labetalol. 1
• ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated due to fetal toxicity. 1
• Target BP: <140/90 mmHg but avoid diastolic <80 mmHg. 1

Older Adults (≥85 years)

• Continue BP-lowering therapy lifelong if well tolerated. 1
• Asymptomatic orthostatic hypotension should not prompt drug withdrawal. 1
• For frail patients or those with limited life expectancy, individualized clinical judgment is reasonable; consider deferring treatment until BP exceeds 140/90 mmHg. 1

Young Adults (<40 years)

• Screen for secondary hypertension causes: renal artery stenosis, primary aldosteronism, pheochromocytoma, Cushing syndrome, coarctation. 1
• In obese young adults, evaluate for obstructive sleep apnea first. 1

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Resistant Hypertension (BP ≥130/80 mmHg Despite ≥3 Agents)

Systematic approach:

1. Confirm true resistance: Use out-of-office monitoring to exclude white-coat effect; assess medication adherence (most common cause of apparent resistance). 1
2. Identify contributing factors: Obesity, excess alcohol, high sodium intake, NSAIDs, obstructive sleep apnea. 1
3. Screen for secondary causes: Primary aldosteronism (most common), renal artery stenosis, pheochromocytoma. 1
4. Optimize diuretic therapy: Use loop diuretics in CKD (eGFR <30). 1
5. Add mineralocorticoid-receptor antagonist: Spironolactone 25–50 mg daily. 1
6. Refer to hypertension specialist if uncontrolled after 6 months. 1

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Common Pitfalls to Avoid

• Delaying combination therapy in Stage 2 hypertension increases cardiovascular risk. 1
• Using β-blockers as first-line in patients >60 years without compelling indication leads to inferior stroke prevention. 1
• Excessive diastolic lowering below 60 mmHg in high-risk patients may increase adverse cardiovascular events. 1
• Failing to employ out-of-office BP monitoring can miss white-coat or masked hypertension. 1
• Assuming treatment failure before confirming adherence is the most common error in resistant hypertension management. 4