Outpatient Management of Blood Pressure

Hypertension Management

• The American College of Cardiology recommends initiating pharmacological treatment when blood pressure is ≥140/90 mmHg (or ≥130/80 mmHg in high-risk patients), targeting <130/80 mmHg for most adults using first-line agents (ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics) with monthly follow-up until target is achieved 1
• The European Heart Journal suggests targeting BP <130/80 mmHg for most adults, though slightly higher targets (up to 140/90 mmHg) may be considered in older adults 2, 1
• Initiate pharmacological treatment when confirmed office BP ≥140/90 mmHg, or ≥130/80 mmHg if 10-year CVD risk ≥10% or high-risk conditions exist 2, 1
• The DASH diet emphasizing fruits, vegetables, whole grains, and low-fat dairy is expected to reduce SBP by 3-5 mmHg 1
• Sodium restriction to <1500 mg/day can reduce BP by 1-3 mmHg per 1000 mg sodium reduction 1
• Weight loss targeting ideal body weight can reduce BP by 1 mmHg per 1 kg lost 1
• Physical activity of 150 minutes/week moderate aerobic exercise is recommended 1
• Alcohol moderation to ≤2 drinks/day for men, ≤1 drink/day for women is advised 1
• First-line agents with proven mortality benefits include ACE inhibitors, ARBs, calcium channel blockers, and thiazide diuretics 1
• For stage 1 hypertension (140-159/90-99 mmHg), start monotherapy with any first-line agent 1
• For stage 2 hypertension (≥160/100 mmHg), start combination therapy with two first-line agents 1
• Preferred formulations include long-acting agents in fixed-dose combinations to improve adherence 1
• In patients with diabetes or CKD, target BP <130/80 mmHg and prefer ACE inhibitors or ARBs 1
• In older adults (≥85 years), follow same guidelines as younger patients if well-tolerated, and consider long-acting dihydropyridine CCBs or RAS inhibitors 2
• Frail patients should be screened for frailty using validated tests and individualize targets considering health priorities and shared decision-making 2
• Monthly visits are recommended until BP target is achieved 1
• Home BP monitoring is advised for medication titration and maintenance 1
• Screen for medication non-adherence, therapeutic inertia, and social determinants of health 1
• Therapeutic inertia, defined as failure to intensify treatment when BP remains above target, should be avoided 1
• Rapid BP reduction should be avoided, as it increases adverse event risk 3
• White coat and masked hypertension should be detected using out-of-office BP monitoring 1
• Polypharmacy without fixed-dose combinations reduces adherence 1

Hypotension Management

• The European Heart Journal recommends prioritizing non-pharmacological interventions for outpatient orthostatic hypotension, including increased dietary salt, adequate hydration, compression therapy, and avoidance of prolonged supine positioning 2
• Screen for orthostatic hypotension by measuring BP after 5 minutes sitting/lying, then at 1 and/or 3 minutes after standing 2
• Diagnostic criteria for orthostatic hypotension include a drop in SBP >20 mmHg or DBP >10 mmHg upon standing 4
• Evaluate for symptomatic hypotension, including dizziness, syncope, headache, visual disturbances, and fatigue 4
• Deprescribe or switch BP-lowering medications that worsen orthostatic hypotension rather than simply de-intensifying therapy 2
• Discontinue or reduce other medications that lower BP, such as sedatives and prostate-specific alpha-blockers 2
• Regular monitoring of both supine and standing BP is recommended 2
• Treating orthostatic hypotension with IV fluids alone is not recommended, as only ~54% respond to fluid bolus 5
• Continuing all BP-lowering medications without review can worsen orthostatic hypotension 2

Risks of Inappropriate Treatment in Outpatient Orthostatic Hypotension

Over‑Treatment of Chronic Hypertension

• In patients with chronic hypertension who develop hypotensive symptoms, rapid lowering of blood pressure may reflect their usual baseline; aggressive reduction can precipitate organ ischemia. 6

Management of Asymptomatic Orthostatic Blood‑Pressure Drops

• Approximately one‑third of individuals who demonstrate an orthostatic systolic/diastolic blood‑pressure decline remain asymptomatic, and initiating treatment in this group does not confer clear benefit. 6