Hypertension Management

Introduction to Hypertension Management

The American College of Cardiology and American Heart Association recommend blood pressure treatment to a target of less than 130/80 mmHg for most adults with hypertension, particularly those with known cardiovascular disease or 10-year ASCVD risk ≥10% 1, 2, 3, 4, 5
The following blood pressure categories are defined:
Category Systolic BP Diastolic BP
Normal <120 <80
Elevated 120-129 <80
Stage 1 Hypertension 130-139 80-89
Stage 2 Hypertension ≥140 ≥90 [1, 6, 3, 5, 1]

The American College of Cardiology recommends obtaining at least 2 readings on at least 2 separate occasions, with the patient seated comfortably for 5 minutes, using validated devices with proper cuff size 1, 5, 1
Proper BP measurement technique is essential, including use of validated devices, patient seated comfortably for 5 minutes, proper cuff size, and averaging multiple readings for accurate diagnosis and treatment decisions 5, 1

The American College of Cardiology recommends using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to detect white coat hypertension and masked hypertension 1, 3, 5, 1
Out-of-office BP measurements (home or ambulatory monitoring) are recommended to confirm diagnosis and guide treatment 1, 5
For HBPM, target blood pressure is <135/85 mmHg (equivalent to clinic blood pressure <140/90 mmHg) 5

The American College of Cardiology recommends a target BP <130/80 mmHg for adults with confirmed hypertension and known CVD or 10-year ASCVD risk ≥10% (Class I recommendation) 1, 2, 3, 4, 5
For adults without additional markers of increased CVD risk, a BP target of <130/80 mmHg may be reasonable (Class IIb recommendation) 2, 7
The primary target is SBP 120-129 mmHg for all adults if tolerated, with a diastolic BP target of 70-79 mmHg 7
More lenient targets (BP <140/90 mmHg) should be considered for individuals with symptomatic orthostatic hypotension, adults aged ≥85 years, or those with moderate-to-severe frailty or limited life expectancy 7

The American College of Cardiology recommends a target BP <130/80 mmHg for ambulatory, community-dwelling adults ≥65 years if tolerated 1, 7
Careful titration and close monitoring are especially important in older adults with high comorbidity burden 1
For adults ≥85 years or with moderate-to-severe frailty, a more lenient target (<140/90 mmHg) may be appropriate 7

The American College of Cardiology recommends the following initial drug selections: ACE inhibitor, ARB, CCB, or thiazide-type diuretic for non-Black patients, CCB or thiazide-type diuretic for Black patients, and ACE inhibitor or ARB for patients with CKD 1, 6, 5
Initial therapy should start with combination therapy using two first-line agents (preferably as single-pill combination) for most patients, with recommended combinations including ACE inhibitor or ARB plus CCB or diuretic 6
Beta-blockers are recommended as first-line therapy only when there are specific indications (e.g., heart failure with reduced ejection fraction) 7

The American College of Cardiology defines resistant hypertension as BP ≥130/80 mmHg despite adherence to 3+ antihypertensive agents from different classes at optimal doses (including a diuretic) 1, 3, 5
The risk for cardiovascular events is 2-6 fold higher than in non-resistant hypertension 1
Screen for secondary causes of hypertension in patients with resistant hypertension, abrupt onset or worsening hypertension, age <30 years at onset, target organ damage disproportionate to blood pressure levels, or unprovoked hypokalemia 3, 5

The American College of Cardiology recommends lifestyle modifications for all patients with elevated BP or hypertension, including a low-sodium diet, regular physical activity, weight loss if overweight/obese, limited alcohol consumption, and adequate potassium intake 8, 4, 2, 1
For Stage 1 Hypertension (130-139/80-89 mmHg) without clinical CVD and 10-year ASCVD risk <10%, start with lifestyle changes only 4, 2, 1
For Stage 1 Hypertension with clinical CVD or 10-year ASCVD risk ≥10%, start drug therapy plus lifestyle changes 4, 2, 1
For Stage 2 Hypertension (≥140/90 mmHg), start drug therapy plus lifestyle changes for all patients, and consider initiation with two first-line agents of different classes when blood pressure is ≥20/10 mmHg above target (Class I recommendation) 4, 2, 5

Follow-up within the first 2 months after initiation of drug therapy, and after achieving BP target, monitor every few months 6, 3, 5
Reassess risk factors and evidence of asymptomatic target organ damage every 2 years 6
Monthly follow-up until blood pressure control is achieved (Class I recommendation) 3, 5
Use home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM) to confirm diagnosis and monitor treatment response 3, 5, 1

A multidisciplinary team-based care approach is recommended (Class I recommendation) 7
Patient-centered care with shared decision-making is also recommended 7
The ACC/AHA recommends systematic strategies including home BP monitoring, team-based care, and telehealth approaches for long-term management 5

For hypertensive emergencies, admit to ICU for continuous monitoring, and reduce systolic blood pressure to <140 mmHg in the first hour for compelling conditions (aortic dissection, severe preeclampsia, pheochromocytoma crisis) 4
For non-compelling conditions, reduce systolic blood pressure by no more than 25% in the first hour, then to 160/100 mmHg within 2-6 hours 4