Hypertension Management Guidelines

Patient Assessment and Risk Stratification

The American College of Cardiology recommends annual blood pressure screening for patients with normal blood pressure (<120/80 mmHg) 1, 2
For patients with elevated blood pressure (120-129/<80 mmHg), the American College of Cardiology suggests initiating nonpharmacological therapy exclusively, with no medications 1, 2
The American College of Cardiology recommends calculating 10-year ASCVD risk using ACC/AHA Pooled Cohort Equations for patients with stage 1 hypertension (130-139/80-89 mmHg) 4
Patients with diabetes or chronic kidney disease are automatically classified as high ASCVD risk, regardless of calculated score 4

The American Heart Association recommends implementing lifestyle modifications, including weight loss, DASH diet, sodium restriction, regular physical activity, and alcohol moderation, for patients with elevated blood pressure 3
The American College of Cardiology suggests counseling patients on maintaining a healthy lifestyle to prevent future hypertension 2

The American College of Cardiology recommends initiating combination therapy with two antihypertensive agents from different classes for patients with stage 2 hypertension (≥140/90 mmHg) 1, 2, 3
For patients with high ASCVD risk (≥10%), the American College of Cardiology suggests initiating combination therapy with an ACE inhibitor, ARB, thiazide diuretic, or calcium channel blocker, along with lifestyle modifications 1, 2, 5
The American College of Cardiology recommends adding spironolactone as a fourth agent for patients with resistant hypertension (uncontrolled on three drugs) 3

For patients with coronary artery disease, the American College of Cardiology recommends ACE inhibitors or ARBs as first-line therapy 3
For patients with albuminuria (UACR ≥30 mg/g), the American College of Cardiology suggests initial treatment with ACE inhibitor or ARB to reduce progressive kidney disease risk 3
For pregnant women or those planning pregnancy, the American College of Cardiology recommends avoiding ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors due to fetal injury and death risk 3

The American College of Cardiology recommends increasing the dose of a single agent to full dose before adding a second agent, and targeting systolic BP 120-129 mmHg for most adults when well tolerated 3
For patients not controlled on two agents, the American College of Cardiology suggests escalating to a three-drug combination within 3 months, and following up every 1-3 months until BP is controlled 3