Hypertension Management Guidelines

Diagnosis and Blood Pressure Classification

The American College of Cardiology defines hypertension as blood pressure ≥130/80 mm Hg, and diagnosis requires confirmation with proper measurement technique using validated devices, with readings obtained on at least two separate occasions 1, 2
Accurate BP measurement requires the patient to sit quietly for >5 minutes with feet flat on the floor, back supported, arm at heart level, using the correct cuff size that encircles 80% of the arm, with no talking during measurement 2
BP classification: Elevated (120-129/<80 mm Hg), Stage 1 (130-139/80-89 mm Hg), Stage 2 (≥140/90 mm Hg) 1, 2, 4

The American College of Cardiology recommends that all newly diagnosed hypertensive patients require basic laboratory testing including fasting glucose, complete blood count, lipid profile, serum creatinine with eGFR, electrolytes, TSH, urinalysis, and electrocardiogram 1
Screen for secondary causes by assessing for BP lability with episodic symptoms, snoring/hypersomnolence, muscle cramps/weakness, medication use, and absence of family history 1

The American Heart Association recommends that all patients with BP >120/80 mm Hg implement lifestyle modifications, which are partially additive to pharmacological therapy and can reduce BP by amounts comparable to single-drug therapy 7
Adopt dietary pattern high in fruits, vegetables, low-fat dairy products, whole grains, and low in saturated fat, such as the DASH diet 7

The American College of Cardiology recommends initiating pharmacological therapy immediately for patients with BP ≥140/90 mm Hg, or BP ≥130/80 mm Hg in high-risk patients with established CVD, diabetes, CKD, or 10-year ASCVD risk ≥10% 8, 9
For Stage 1 hypertension, attempt lifestyle modifications alone for 3-6 months before initiating medication 5, 6
The four first-line medication classes are thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, and long-acting dihydropyridine calcium channel blockers—all equally effective at reducing cardiovascular morbidity and mortality 5

The American College of Cardiology recommends targeting BP <130/80 mm Hg for most adults <65 years; target systolic BP <130 mm Hg for adults ≥65 years if tolerated 5, 6, 3
For adults ≥60 years without high-risk conditions, target SBP <150 mm Hg is acceptable (strong recommendation, high-quality evidence) 7

If BP remains above goal on initial two-drug combination, switch to single-pill combination of ACE inhibitor or ARB plus calcium channel blocker plus thiazide-like diuretic 3
Titrate medications every 2-4 weeks until BP target achieved, with goal of reaching target within 3 months 5

Monitor serum creatinine and potassium within 7-14 days after initiating or titrating ACE inhibitors, ARBs, or diuretics, then at least annually 5, 3
Accept creatinine increases up to 30% from baseline after RAS blocker initiation—this reflects beneficial reduction in intraglomerular pressure 5

Reassess BP 7-14 days after medication initiation or dose changes; once stable, follow-up every 3-6 months for patients at goal, monthly for those not at goal 5, 6

Never combine ACE inhibitors with ARBs—this increases adverse effects without additional cardiovascular or renal benefit 5, 3
ACE inhibitors and ARBs are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential not using reliable contraception 5

Use single-pill combination medications when multiple drugs are needed, implement team-based care with pharmacists and nurses, and utilize home BP monitoring with telehealth follow-up 6, 3
Prescribe 90-day refills instead of 30-day when allowed 5
Employ motivational interviewing and goal-setting strategies to improve patient engagement 6, 3