Blood Pressure Management Guidelines

Diagnosis and Confirmation

Hypertension is diagnosed when office blood pressure is ≥140/90 mmHg on repeated measurements across 2-3 visits, confirmed with home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 1, 2
Use validated automated upper arm cuff devices with appropriate cuff size for accurate measurement 2
Take the average of at least 2 readings per visit 1
At first visit, measure BP in both arms simultaneously; if there is a consistent difference, use the arm with higher readings 2

The European Society of Cardiology recommends an initial target of <140/90 mmHg for all patients, then targeting 120-129/<80 mmHg if well tolerated, with 120 mmHg being the optimal systolic target 3, 4
General population: 120-129/<80 mmHg (optimal target if tolerated) 3, 4
Initial target for all patients: <140/90 mmHg 1, 3, 5
Patients with known CVD: <130 mmHg systolic (strong recommendation) 1, 5
High-risk patients (diabetes, CKD, high CVD risk): <130 mmHg systolic 1, 5
Diastolic target: 70-79 mmHg for all patients 3

For non-Black patients, initiate therapy with ACE inhibitors, ARBs, long-acting dihydropyridine calcium channel blockers, or thiazide/thiazide-like diuretics 1, 3, 2
For Black patients, initiate with ARB plus calcium channel blocker or calcium channel blocker plus thiazide/thiazide-like diuretic 2
Beta-blockers are NOT first-line agents except when there is a compelling indication (heart failure with reduced ejection fraction, recent MI, angina) 3, 4

BP ≥160/100 mmHg (Grade 2 hypertension): Start immediate drug therapy 3, 2
BP 140-159/90-99 mmHg (Grade 1 hypertension) in high-risk patients: Start immediate drug therapy 2
High-risk criteria include: Established CVD, Chronic kidney disease, Diabetes mellitus, Target organ damage, Age 50-80 years 2

Most patients require combination therapy to achieve BP targets; single-pill combinations are preferred to improve adherence 1, 6
Never combine ACE inhibitors with ARBs due to increased adverse effects without additional benefit 6

After initiating or changing antihypertensive medications, follow up monthly until BP target is achieved 1, 5
Target BP control should be achieved within 3 months 6, 3, 2
Once controlled, follow up every 3-5 months 1, 5

All patients with BP ≥130/85 mmHg should implement lifestyle modifications, which have additive effects with pharmacotherapy 1
Dietary sodium restriction: <100 mmol/day (2300 mg) for prevention; 65-100 mmol/day (1500-2300 mg) for treatment 1
Weight management: BMI 18.5-24.9 kg/m²; waist circumference <94 cm (men), <80 cm (women) 3
Aerobic exercise: 30-60 minutes, 4-7 days per week 1
DASH diet: Increased vegetables, fruits, fish, nuts, unsaturated fatty acids; low-fat dairy; reduced red meat 3
Alcohol restriction: <14 units/week (men), <8 units/week (women); ideally avoid completely 3

Heart Failure with Reduced Ejection Fraction: ACE inhibitors + beta-blockers (first-line) 6
Recent Myocardial Infarction: Beta-blockers + ACE inhibitors (first-line) 6
Angina: Beta-blockers + ACE inhibitors (first-line) 6
Diabetes Mellitus: ACE inhibitors or ARBs (first-line) 1
Chronic Kidney Disease (non-diabetic): ACE inhibitors (first-line) 6
Pregnancy or Planning Pregnancy: Beta-blockers (first-line) 6

Diastolic J-curve concern: Lowering diastolic BP to <60 mmHg may increase cardiovascular risk in patients with high CVD risk and treated systolic BP <130 mmHg 1
Orthostatic hypotension: Check for symptomatic orthostatic hypotension before intensifying therapy, particularly in elderly patients 3
Frailty assessment: In frail elderly patients, tailor treatment to achieve the best BP possible within target range while monitoring for adverse effects rather than rigidly pursuing intensive targets 6, 3
Adherence: Single-pill combinations significantly improve adherence and should be used preferentially when combination therapy is required 1, 6