Hypertension Management Guidelines

Diagnostic Criteria and Treatment Initiation

The American College of Cardiology and American Heart Association recommend diagnosing hypertension when blood pressure is ≥130/80 mm Hg, replacing the older threshold of ≥140/90 mm Hg 1, 2
The American College of Cardiology and American Heart Association guidelines classify blood pressure as follows: Normal (<120/80 mm Hg), Elevated (120-129/<80 mm Hg), Stage 1 Hypertension (130-139/80-89 mm Hg), and Stage 2 Hypertension (≥140/90 mm Hg) 1, 3
Initiate pharmacotherapy at BP ≥130/80 mm Hg for Stage 1 hypertension, particularly in patients with established cardiovascular disease, diabetes, chronic kidney disease, or 10-year ASCVD risk ≥10% 1, 2
Initiate pharmacotherapy at BP ≥140/90 mm Hg for Stage 2 hypertension in all patients 1, 2

The American College of Cardiology recommends thiazide or thiazide-like diuretics, particularly chlorthalidone, as the optimal first-line choice for most adults with hypertension, based on the strongest evidence for reducing cardiovascular mortality, stroke, and heart failure 1, 4, 5
Chlorthalidone 12.5-25 mg once daily is superior to other agents based on the ALLHAT trial, showing better outcomes than ACE inhibitors for stroke prevention and better than calcium channel blockers for heart failure prevention 1, 4, 5
Long-acting dihydropyridines, such as amlodipine 5-10 mg once daily, are equally effective as thiazides for all cardiovascular events except heart failure 1, 6, 4
ACE inhibitors, such as lisinopril 10-40 mg once daily, are effective first-line options, particularly for patients with albuminuria or established coronary artery disease 1, 6, 7
Angiotensin Receptor Blockers (ARBs), such as losartan 50-100 mg once daily, are equally effective to ACE inhibitors 6, 7, 8

For most adults without comorbidities, start with chlorthalidone 12.5-25 mg once daily, and switch to amlodipine 5-10 mg once daily if not tolerated 1, 4, 5
For Black patients without heart failure or CKD, start with thiazide diuretic or calcium channel blocker, and avoid ACE inhibitors/ARBs as monotherapy 1, 5, 8
For patients with diabetes, all four first-line classes are equally effective, and consider ACE inhibitor or ARB if albuminuria is present 2, 7, 8
For patients with chronic kidney disease or albuminuria, ACE inhibitor or ARB is mandatory first-line therapy to reduce progressive kidney disease 7, 8

For Stage 1 hypertension, start with single-agent therapy and titrate dosage, then add sequential agents if needed to reach target <130/80 mm Hg 1, 5, 8
For Stage 2 hypertension, start with two first-line agents from different classes, preferably as a single-pill combination, and consider combinations such as ACE inhibitor/ARB + CCB, ACE inhibitor/ARB + thiazide, or CCB + thiazide 1, 6, 5, 8

The general population should aim for a blood pressure goal of <140/90 mm Hg (strong recommendation) 6
Patients with known CVD should aim for a blood pressure goal of <130/80 mm Hg (strong recommendation) 6, 9
High-risk patients, such as those with diabetes, CKD, or high CVD risk, should consider a blood pressure goal of <130/80 mm Hg (conditional recommendation) 6, 9

Patients should be reassessed monthly after medication initiation or changes until target BP is achieved, and then every 3-5 months once blood pressure is controlled 6, 8
Electrolytes and renal function should be monitored within 7-14 days when starting ACE inhibitors, ARBs, or diuretics, and then at least annually 5, 8
Standing BP should be checked in elderly patients to assess for orthostatic hypotension 4