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Management of Hypertension — Current Guidelines

1. Classification (ACC/AHA 2017, reaffirmed in current practice)

Correct classification requires averaging ≥2 readings on ≥2 separate occasions. When SBP and DBP fall in different categories, use the higher classification. — Harrison's Principles of Internal Medicine 22E (2025)

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2. Blood Pressure Measurement

• Office BP alone is insufficient — complement with out-of-office readings
• White-coat hypertension (high office, normal home BP): prevalence ~15–25%; manage with nonpharmacologic therapy and monitoring
• Masked hypertension (normal office, high home BP): prevalence ~15–25%; carries CVD risk similar to sustained hypertension — treat with antihypertensive drugs + lifestyle
• Home BP devices must be clinically validated; measure morning and evening (average of 2–3 readings each)
• Control targets apply equally to office and home measurements: SBP/DBP <130/80 mmHg

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3. Treatment Goals (BP Targets)

• SPRINT: SBP target 120 vs 140 mmHg → 34% reduction in CV events, 33% reduction in mortality in adults ≥75 years
• HYVET: Indapamide to SBP <150 mmHg in patients ≥80 → 39% reduction in fatal stroke, 21% reduction in all-cause mortality, 64% reduction in HF

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4. Lifestyle Modifications (First-Line for All Stages)

~70% of dietary sodium comes from processed food — advising patients to "not add salt" is insufficient. — Goldman-Cecil Medicine, International Edition

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5. Pharmacologic Treatment

When to Start Drugs

• Stage 1 hypertension (130–139/80–89): lifestyle modification first; add drugs if 10-year ASCVD risk ≥10% or if target organ damage/clinical CVD present
• Stage 2 hypertension (≥140/90): initiate drug therapy alongside lifestyle changes
• Most patients require ≥2 drugs to reach target BP

First-Line Drug Classes (Four Major Classes)

1. Thiazide/thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide, indapamide)
2. ACE inhibitors (ACEIs)
3. Angiotensin receptor blockers (ARBs)
4. Calcium channel blockers (CCBs) — dihydropyridines preferred

Combination therapy allows lower individual doses, minimizes dose-dependent side effects, achieves longer action, and provides additive organ protection. — Braunwald's Heart Disease

Preferred Combinations

• Single-pill combinations (once daily) maximize adherence
• ~20% of new prescriptions are never filled; ~50% are discontinued by 1 year — simplification is essential
• Complementary mechanisms: RAS blocker + CCB or thiazide is highly effective

Drug Selection by Comorbidity

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6. Special Populations

Elderly (≥65–75 years)

• Isolated systolic hypertension accounts for >90% of hypertension after age 70
• Start at lowest doses, titrate gradually
• Assess BP both seated and standing (orthostatic hypotension risk)
• In older adults with CHD, avoid excessive DBP lowering (<60–65 mmHg)

CKD

• ACEIs/ARBs slow CKD progression beyond BP reduction
• A <30% reduction in GFR after starting ACEIs/ARBs is acceptable and may reflect beneficial efferent arteriolar dilation
• Continue RAS inhibitors even with eGFR <30 mL/min (stopping them increases risk of death/CV events); monitor potassium closely
• Use kaliuretic diuretics (furosemide + metolazone) or potassium binders (patiromer) to manage hyperkalemia
• Avoid potassium-sparing diuretics (amiloride, triamterene) in most CKD patients

Race/Ethnicity

• Black patients: higher prevalence, earlier onset, higher risk of CVD and kidney disease; diuretics and CCBs particularly effective
• BP control rates remain ~15% lower in Black vs White Americans due largely to social determinants of health

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7. Hypertensive Urgency vs Emergency

Each 5-mmHg reduction in SBP corresponds to approximately a 10% reduction in cardiovascular events. — Goldman-Cecil Medicine, International Edition

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8. Monitoring & Follow-Up

• After initiating or intensifying therapy: recheck BP within 1 month
• Once stable and at goal: follow up every 3–6 months
• Monitor renal function and electrolytes (especially with ACEIs/ARBs + diuretics)
• Address non-BP risk factors concurrently (dyslipidemia, diabetes, smoking)
• Global ASCVD risk reduction is the ultimate goal — successfully treated hypertensives retain higher residual risk than normotensives at the same BP level

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