Hypertension Management Guidelines

Diagnosis and Assessment

Blood pressure should be measured using a validated device with the patient seated, arm at heart level, with at least two measurements at each visit 2
Ambulatory blood pressure monitoring is indicated for unusual BP variability, suspected white coat hypertension, or resistant hypertension 1
Routine investigations should include urine testing for blood and protein, blood electrolytes and creatinine, blood glucose, serum cholesterol, and 12-lead ECG 3
Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions 2

Urgent treatment is needed for accelerated hypertension, severe hypertension, or impending complications 1
Standard treatment thresholds include starting drug treatment in all patients with sustained SBP ≥ 160 mm Hg or DBP ≥ 100 mmHg 1, 4
For patients with SBP 140-159 mm Hg or DBP 90-99 mm Hg, treat if target organ damage, established cardiovascular disease, diabetes, or 10-year CVD risk ≥ 20% 1

For most patients, the target blood pressure is ≤ 140 mm Hg systolic and ≤ 85 mm Hg diastolic 1, 4
For patients with diabetes, renal impairment, or established cardiovascular disease, the target blood pressure is ≤ 130/80 mm Hg 1, 5
When using ambulatory BP readings, targets should be approximately 10/5 mm Hg lower than office BP equivalents 1

Lifestyle measures should be recommended to all patients with hypertension and those with borderline or high-normal blood pressure 1, 4
Effective lifestyle interventions include weight reduction, regular physical activity, limiting alcohol consumption, and reduced sodium intake 2

When no compelling indications exist, initial drug selection should follow the AB/CD algorithm 1
First-line agents include thiazide or thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), calcium channel blockers, and beta-blockers 1

Secondary hypertension should be suspected with elevated serum creatinine or proteinuria/hematuria, sudden onset or worsening of hypertension, resistance to multiple drugs, young age, or electrolyte abnormalities suggesting endocrine causes 1
Pregnancy requires specialized management 1
Resistant hypertension should consider secondary causes and medication adherence 1

Failing to confirm elevated readings with multiple measurements before diagnosis 2
Not considering white coat hypertension when office readings are elevated 1
Inadequate dosing or inappropriate combinations of antihypertensive medications 1
Not addressing lifestyle modifications alongside pharmacological treatment 1
Overlooking the need for lower BP targets in high-risk patients (diabetes, CKD, established CVD) 1, 5
Not considering secondary causes in resistant hypertension or young patients 1

Regular monitoring of BP (office and home readings when possible) is necessary 1
Annual reassessment of cardiovascular risk is recommended 1
Monitoring for adverse effects of medications and adjusting therapy as needed is crucial 1