Latest guidelines for management of hypertension
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The most relevant sources are Harrison's (2025), Braunwald's Heart Disease, and Fuster & Hurst's Heart. Let me read those sections in parallel.
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The Harrison's block 34 returned CKD hypertension content. Let me find the main hypertension management section in Harrison's and Braunwald's directly.
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The main hypertension chapter in Harrison's is block 30 (starting at line 1777) and block 54. Let me read those key sections in parallel.
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Excellent content from both Harrison's and Goldman-Cecil. The Harrison's block 30 content was very rich. Let me read more of the Goldman-Cecil treatment section and more of Harrison's block 30 (which contains the full treatment algorithm).
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I now have comprehensive content from Harrison's 22E (2025) and Goldman-Cecil Medicine. Let me compile a thorough, well-structured response.
Management of Hypertension — Current Guidelines
1. Classification (ACC/AHA 2017, reaffirmed in current practice)
| Category | Systolic (mmHg) | Diastolic (mmHg) | |
|---|---|---|---|
| Normal | <120 | and | <80 |
| Elevated | 120–129 | and | <80 |
| Stage 1 Hypertension | 130–139 | or | 80–89 |
| Stage 2 Hypertension | ≥140 | or | ≥90 |
| Hypertensive Crisis | ≥180 | and/or | ≥100 |
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)
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
3. Treatment Goals (BP Targets)
| Patient Population | Target BP |
|---|---|
| General adults | <130/80 mmHg |
| Adults ≥75 years (SPRINT trial evidence) | <130 mmHg systolic |
| Very elderly ≥80 years (HYVET trial) | <150/80 mmHg as minimum |
| CKD with diabetes or proteinuria >1 g/24h | <130/80 mmHg |
| CHD (to avoid J-curve) | Avoid DBP <60–65 mmHg |
Key trial data:
- 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
4. Lifestyle Modifications (First-Line for All Stages)
These reduce SBP by 7–15 mmHg and are core for both primordial prevention and treatment:
| Intervention | Effect on SBP |
|---|---|
| DASH diet (high fruits, vegetables, low-fat dairy, whole grains; low saturated fat) | ~6 mmHg |
| Sodium restriction (<1500 mg/day preferred; <2000 mg/day minimum) | ~5 mmHg |
| Aerobic or dynamic resistance exercise, 90–150 min/week | ~4–8 mmHg |
| Weight reduction | ~1 mmHg per kg lost |
| Alcohol limitation (≤2 drinks/day men; ≤1 drink/day women) | ~3–4 mmHg |
| Smoking cessation | Reduces overall CV risk |
~70% of dietary sodium comes from processed food — advising patients to "not add salt" is insufficient. — Goldman-Cecil Medicine, International Edition
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)
- Thiazide/thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide, indapamide)
- ACE inhibitors (ACEIs)
- Angiotensin receptor blockers (ARBs)
- 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
| Condition | Preferred Agents |
|---|---|
| CKD (especially with proteinuria) | ACEI or ARB (reduce intraglomerular hypertension beyond BP lowering) |
| Diabetes + CKD | ACEI or ARB |
| Post-MI / CHD | Beta-blockers, ACEIs, ARBs |
| Heart failure with reduced EF | ACEIs/ARBs, beta-blockers, mineralocorticoid antagonists |
| Isolated systolic hypertension (elderly) | Thiazides, CCBs |
| Black patients | Diuretics and CCBs especially effective; often need triple therapy |
| Pregnancy | ACEIs and ARBs contraindicated |
| Osteoporosis risk (women) | Thiazide diuretics reduce urinary calcium excretion (protective) |
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
7. Hypertensive Urgency vs Emergency
| Urgency | Emergency | |
|---|---|---|
| BP level | ≥180/100 mmHg | ≥180/100 mmHg |
| Symptoms | Asymptomatic | Active end-organ damage |
| Management | Oral antihypertensives, outpatient intensification | IV antihypertensives, emergency/inpatient setting |
End-organ damage in hypertensive emergency: hypertensive encephalopathy (headache, visual defects, nausea, vomiting, seizures), acute LV failure, acute kidney injury
Conditions requiring especially rapid reduction: acute aortic dissection, eclampsia/severe preeclampsia, pheochromocytoma crisis
IV agents used in hypertensive emergency: sodium nitroprusside, labetalol, nicardipine, clevidipine, hydralazine (in eclampsia)
Each 5-mmHg reduction in SBP corresponds to approximately a 10% reduction in cardiovascular events. — Goldman-Cecil Medicine, International Edition
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
Sources: Harrison's Principles of Internal Medicine 22E (2025), Goldman-Cecil Medicine International Edition, Braunwald's Heart Disease, Fuster and Hurst's The Heart 15th Edition
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