Outpatient Management of Hypertension

Initial Assessment and Blood Pressure Goals

The American College of Cardiology and other guideline societies recommend blood pressure targets of <130/80 mmHg for most adults, with consideration for slightly higher targets in older adults 2, 3
The American Heart Association suggests that thresholds for initiating pharmacological treatment range from >140/90 mmHg to >160/100 mmHg depending on overall cardiovascular risk 2
Proper BP measurement technique is essential, including repeated measurements and consideration of both arms 4
Monthly visits are recommended until blood pressure target is achieved, with a strength of evidence level of high 1

The American College of Cardiology recommends a DASH diet, emphasizing fruits, vegetables, whole grains, and low-fat dairy products, with an expected SBP reduction of 3-5 mmHg 1
Weight loss is recommended, aiming for ideal body weight, with an expected 1 mmHg SBP reduction per 1 kg weight loss, and a moderate level of evidence 1
Sodium restriction is advised, targeting <1500 mg sodium/day, with an expected 1-3 mmHg SBP reduction per 1000 mg sodium reduction, based on strong evidence 1
Increased potassium intake is suggested, aiming for 3500-5000 mg potassium/day through dietary sources, with a moderate level of evidence 1
Physical activity is recommended, consisting of 150 minutes/week of moderate aerobic exercise, with a high level of evidence 1
Alcohol moderation is advised, limiting intake to ≤2 standard drinks/day for men and ≤1 standard drink/day for women, based on moderate evidence 1

The American Heart Association recommends four primary first-line medication classes with proven mortality benefits: ACE inhibitors, ARBs, calcium channel blockers, and thiazide diuretics, with a high level of evidence 2, 1
For stage 1 hypertension, monotherapy with any first-line agent is suggested, while combination therapy is recommended for stage 2 hypertension, based on strong evidence 2
Fixed-dose combinations are preferred to improve adherence, with a moderate level of evidence 1
Long-acting formulations are recommended, such as amlodipine and chlorthalidone, based on high-quality evidence 1

For patients with diabetes, a target BP of <130/80 mmHg is recommended, with ACE inhibitors or ARBs preferred, based on strong evidence 2, 5
In patients with chronic kidney disease, a target BP of <130/80 mmHg is advised, with ACE inhibitors or ARBs preferred, with a high level of evidence 2
Older adults may require slightly higher BP targets and more gradual BP reduction, based on moderate evidence 2
Frail patients, those with dementia, or multi-morbidity require individualized BP targets to reduce side effects and promote quality of life, with a low level of evidence 2

Monthly visits are recommended until blood pressure target is achieved, with a high level of evidence 1
Home blood pressure monitoring is suggested for medication titration and maintenance of BP goals, based on moderate evidence 1, 3
Follow-up within 1 month is recommended for moderately elevated BP and within 1 week for severely elevated BP, with a high level of evidence 3, 4
Telehealth strategies may be used to augment office-based management, based on low-quality evidence 1
Screening for social determinants of health and obstacles to care is advised, with a moderate level of evidence 1

Therapeutic inertia, or failure to intensify treatment when BP remains above target, should be avoided, based on high-quality evidence 1
Medication non-adherence can be improved with fixed-dose combinations and 90-day refills, with a moderate level of evidence 1
White coat hypertension and masked hypertension require out-of-office BP monitoring for detection, based on moderate evidence 1
Rapid BP reduction should be avoided, as it may increase the risk of adverse events, with a low level of evidence 6