Initial Management of Hypertension in Adults

Diagnosis and Treatment Approach

The American Heart Association recommends confirming the diagnosis with out-of-office blood pressure monitoring before initiating drug therapy, particularly in patients with low cardiovascular disease risk 1, 2
The American College of Cardiology suggests initiating lifestyle modifications alone for patients with stage 1 hypertension and low cardiovascular risk (<10% 10-year ASCVD risk) 1
For patients with stage 1 hypertension and high cardiovascular risk (≥10% 10-year ASCVD risk), the American Heart Association recommends initiating both lifestyle modifications and antihypertensive drug therapy simultaneously 1
The American College of Cardiology recommends initiating combination therapy with two antihypertensive agents from different classes plus lifestyle modifications for patients with stage 2 hypertension 1

The American Heart Association suggests implementing lifestyle modifications, including weight loss, dietary sodium restriction, dietary potassium supplementation, DASH dietary pattern, regular physical activity, alcohol moderation, and smoking cessation, as they have additive BP-lowering effects 2

The American College of Cardiology recommends choosing from four equally effective first-line drug classes: thiazide or thiazide-like diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs), and long-acting calcium channel blockers 1, 2
For stage 2 hypertension, the American Heart Association suggests starting with two medications from different classes simultaneously, such as ACE inhibitor or ARB + calcium channel blocker, or ACE inhibitor or ARB + thiazide diuretic 1, 2

The American College of Cardiology recommends targeting BP <130/80 mmHg for most adults <65 years and SBP <130 mmHg for adults ≥65 years 1
Intensive BP control (targeting <130/80 mmHg) reduces cardiovascular events by 20-30% for every 10 mmHg SBP reduction, according to the American Heart Association 2

The American Heart Association recommends using home BP monitoring (HBPM) as the most practical method for medication titration toward BP goal and scheduling monthly follow-up visits until target BP is achieved 1, 2