Hypertension Management Guidelines

Initial Treatment Approach

The American College of Cardiology recommends first-line pharmacological therapy to include one of four medication classes: thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers, combined with lifestyle modifications 1, 2
Sodium restriction to <2,300 mg/day is recommended for all patients with elevated blood pressure 1
Weight loss targeting BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) is recommended if overweight 1
Moderate-intensity aerobic exercise ≥150 minutes/week plus resistance training 2-3 times/week is recommended 1
Adopting Mediterranean or DASH dietary patterns with increased potassium intake is recommended 1, 2
Alcohol limitation to <100g/week of pure alcohol is recommended, with complete avoidance preferred 1
Smoking cessation is recommended 1

For patients with albuminuria (UACR ≥30 mg/g), ACE inhibitor or ARB is mandatory first-line therapy to reduce proteinuria and slow kidney disease progression 1, 2, 3
For patients with coronary artery disease, ACE inhibitor or ARB is recommended as first-line therapy 1, 2, 3
For patients with diabetes and albuminuria (UACR ≥300 mg/g), ACE inhibitor or ARB is strongly recommended 3
For black patients, calcium channel blockers or thiazide diuretics are more effective than ACE inhibitors or ARBs when used as monotherapy 1, 2

Combination therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide-like diuretic is recommended as initial therapy for most patients with confirmed hypertension 1
Thiazide-like diuretics, ACE inhibitors, ARBs, and dihydropyridine calcium channel blockers are equally effective first-line classes 1, 2, 3
If BP is not controlled with two-drug combination, progress to three-drug combination (RAS blocker + calcium channel blocker + thiazide-like diuretic) 1
If BP is not controlled with three drugs from different classes, consider adding a mineralocorticoid receptor antagonist and refer to specialist with expertise in BP management 3

Monitor serum creatinine and potassium within 7-14 days after initiation of ACE inhibitors, ARBs, or diuretics, then at least annually 2, 3
Follow-up within 7-14 days after medication initiation or dose changes, with goal of achieving BP target within 3 months 2

Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 1, 2, 3
Never combine ACE inhibitor or ARB with direct renin inhibitor due to lack of benefit and increased adverse events 3
ACE inhibitors and ARBs are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential not using reliable contraception 2
Adding mineralocorticoid receptor antagonists to ACE inhibitor or ARB increases hyperkalemia risk, requiring regular monitoring of serum creatinine and potassium 3
Continue ACE inhibitor or ARB therapy even as kidney function declines to eGFR <30 mL/min/1.73 m² for cardiovascular benefit without significantly increasing end-stage kidney disease risk 3
Bedtime dosing of antihypertensives is not recommended as prior benefits have not been reproduced in subsequent trials 3