SUMMARY:

Treatment of hypertension should involve non-pharmacologic therapy (also called lifestyle modification) alone or in concert with antihypertensive drug therapy.  The ACC/AHA Blood Pressure Guidelines address both areas. In addition, the AHA scientific statement (2019) on BP measurement concluded that validated oscillometric devices allow for accurate BP measurement in the outpatient setting and “may provide a more accurate measurement of BP than auscultation”

Table of Contents  

• Current ACC/AHA Definitions
• Lab Work-Up
• BP Treatment Summary
• Lifestyle Modification
• First Line Pharmacological Treatment
• Second Line Pharmacological Treatment
• Target BP and Treatment Strategy
• Special Populations

Current ACC/AHA Definitions

(See ‘Related ObG Entry’ below)

• Normal
  • Systolic <120 mmHg and diastolic <80 mmHg
• Elevated
  • Systolic 120 to 129 mmHg and diastolic <80 mmHg
• Hypertension
  • Stage 1: Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg
  • Stage 2: Systolic ≥140 mmHg or diastolic ≥90 mmHg
• ‘White Coat’ hypertension
  • Elevated BP in the office but not outside the office
  • Checking for ‘White Coat’ hypertension using either daytime Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM) is “reasonable” if
    • Office SBP is >130 but <160 mm Hg or
    • Office diastolic BP (DBP) >80 but <100 mm Hg
• ‘Masked’ hypertension
  • Elevated BP out-of-office but not in-office
  • Checking for ‘masked’ hypertension with daytime ABPM or HBPM is “reasonable if”
    • Office SPB is 120 to 129 and DBP is <80
• Hypertensive emergency (formerly called ‘malignant hypertension’)
  • Severe hypertension: SBP ≥180 mmHg or DBP ≥120 mmHg
  • Consider this a medical emergency which may need ICU care
• Resistant hypertension
  • Uncontrolled BP despite treatment ≥3 antihypertensive agents (one of which is usually a diuretic)

Lab Work-Up

• Basic
  • Fasting blood glucose | Sodium | Potassium | Calcium
    • Can be part of comprehensive metabolic panel
  • Serum creatinine with eGFR
  • CBC
  • Lipid profile
  • TSH
  • Urinalysis
  • Electrocardiogram
• Optional testing
  • Echocardiogram
  • Uric acid
  • Urinary albumin/creatinine ratio

BP Treatment Summary

• <120 mmHg and <80 mmHg → NORMAL BP
  • Healthy lifestyle choices  
  • Yearly check-ups 
• 120 – 129 mmHg and <80 mmHg → ELEVATED BP
  • Lifestyle changes  
  • Reassess in 3 to 6 months  
• 130 – 139 mmHg or 80-89 mmHg → HIGH BP – STAGE 1  
  • 10-year heart disease and stroke risk assessment <10% risk 
    • Lifestyle changes  
    • Re-assess in 3 to 6 months 
  • 10-year heart disease and stroke risk assessment ≥10% risk 
    • Lifestyle changes  
    • Medication  
    • Monthly follow-up until BP is under control 
• ≥140 mmHg or ≥90 mmHg → HIGH BP – STAGE 2 
  • Lifestyle changes  
  • Consider initiation of therapy with 2 different classes of medications 
  • Monthly follow-up until BP is under control
  • If BP ≥160/100 mm Hg: Treat promptly, monitor carefully and adjust medication dose upward as necessary to achieve control  

NOTE: Calculate 10-year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk (see ‘Learn More – Primary Sources’ below)

Lifestyle Modification (Non-pharmacological Interventions) 

• Weight loss 
  • Goal: Optimum goal is ideal body weight but can expect 1mm Hg for every 1kg reduction 
• Diet 
  • DASH diet: Fruits and vegetables, whole grains, low-fat dairy products, reduced saturated and total fat 
  • Other diets with supportive evidence 
    • Low in calories from carbohydrates  
    • High-protein diets  
    • Vegetarian diets  
    • Mediterranean dietary pattern  
  • Sodium: Goal <1500 mg/d, but aim for at least a 1000-mg/d reduction 
  • Potassium: Goal 3500 to 5000 mg/d, preferably through diet 
• Exercise – Recommend structured exercise program  
  • Aerobic: 90–150 min/wk; 65%–75% heart rate reserve 
  • Dynamic resistance and Isometric resistance also shown to lower BP  
• Alcohol Reduction (drink = 12 oz regular beer [5% alc] / 5 oz wine [12% alc] / 1.5 oz distilled spirits [40% alc])  
  • Women: ≤ 1 drink per day  
  • Men: ≤ 2 drink per day 

First Line Pharmacological Treatment

Dosages based on ACC/AHA guidelines and may differ from FDA labeling

Thiazide or thiazide-type diuretics

• Chlorthalidone: 12.5–25 mg/d
  • Preferred due to prolonged half-life and evidence of reduced adverse CVD outcomes
  • Monitor for: Hyponatremia & hypokalemia | Uric acid & calcium levels
  • Caution: Ask about history of acute gout unless patient is on uric acid–lowering therapy
• Hydrochlorothiazide: 25–50 mg/d
• Indapamide: 1.25–2.5 mg/d
• Metolazone: 2.5–5 mg/d

ACE (angiotensin-converting-enzyme) inhibitors

• Benazepril: 10–40 mg/d (divided in to 1 or 2 doses)
• Captopril: 12.5–150 mg/d (divided in to 2 or 3 doses)
• Enalapril: 5–40 mg/d (divided in to 1 or 2 doses)
• Fosinopril 10–40 mg/d
• Lisinopril: 10–40 mg/d
• Moexipril 7.5–30 mg/d (divided in to 1 or 2 doses)
• Perindopril: 4–16 mg/d
• Quinapril: 10–80 mg/d (divided in to 1 or 2 doses)
• Ramipril: 2.5–20 mg/d (divided in to 1 or 2 doses)
• Trandolapril: 1–4 mg/d

Caution: Do not combine with ARBs or direct renin inhibitor | Increased risk of hyperkalemia (watch for patients with CKD, on K⁺ supplements or sparing meds) | Risk for acute renal failure in patients with severe bilateral renal artery stenosis | Do not use in pregnancy | Do not use if patient has history of angioedema with ACE inhibitors

ARBs (Angiotensin II Receptor Blockers)

• Azilsartan: 40–80 mg/d
• Candesartan: 8–32 mg/d
• Eprosartan: 600–800 mg/d (divided in to 1 or 2 doses)
• Irbesartan: 150–300 mg/d
• Losartan: 50–100 mg/d (divided in to 1 or 2 doses)
• Olmesartan: 20–40 mg/d
• Telmisartan: 20–80 mg/d
• Valsartan: 80–320 mg/d

Caution: Do not combine with ACE or direct renin inhibitor | Increased risk of hyperkalemia (watch for patients with CKD, on K⁺ supplements or sparing meds) | Risk for acute renal failure in patients with severe bilateral renal artery stenosis | Do not use in pregnancy | Do not use if patient has history of angioedema with ARBs | Note: Patient with history of angioedema due to ACE inhibitor can start ARBs six weeks after ACE inhibitor has been stopped

CCB (Calcium Channel Blocker): Dihydropyridines

• Amlodipine: 2.5–10 mg/d
• Felodipine: 2.5–10 mg/d
• Isradipine: 5–10 mg/d (divided in to 2 doses)
• Nicardipine SR: 60–120 (divided in to 2 doses)
• Nifedipine LA: 30–90 mg/d
• Nisoldipine: 17–34 mg/d

Caution: Avoid use in patients with heart failure/reduced ejection fraction (HFrEF) – amlodipine or felodipine may be used if required | Dose-related pedal edema is more common in women

CCB: Nondihydropyridines

• Diltiazem ER: 120–360 mg/d
• Verapamil IR: 120–360 mg/d (divided in to 3 doses)
• Verapamil SR: 120–360 mg/d (divided in to 1 or 2 doses)
• Verapamil-delayed onset ER: 100–300 mg/d (1 dose in the evening)

Caution: Avoid routine use with beta blockers due to increased risk of bradycardia and heart block| Avoid in patients with HFrEF | Note drug interactions with diltiazem and verapamil (CYP3A4 major substrate and moderate inhibitor)

Second Line Pharmacological Treatment

Complete list with dosing available in the guideline link (see ‘Learn More – Primary Sources’ below)

• Second line treatment includes the following classes of medications
  • Diuretics: Loop | Potassium sparing | Aldosterone antagonists
  • Beta-blockers: Cardioselective | cardioselective and vasodilatory | noncardioselective | intrinsic sympathomimetic activity | combined alpha- and beta-receptor |
  • Direct renin inhibitor
  • Alpha-1 blockers
  • Central alpha2 agonist and other centrally acting drugs
  • Direct vasodilators
• While some are generally less effective than first-line class drugs, some may be preferred in certain clinical settings such as symptomatic heart failure  

KEY POINTS:

Target BP and Treatment Strategy

 BP Target Goals

• Known CVD or 10-year ASCVD event risk >10%
  • <130/80 mm Hg “is recommended”
• No additional markers for CVD risk
  • <130/80 mm Hg “may be reasonable”  

Monotherapy vs Combination Therapy

• Stage 1 hypertension
  • Start with a single agent Initiation of antihypertensive drug therapy and titrate dose or add another medication to achieve target  
• Stage 2 hypertension and an average BP more than 20/10 mm Hg above BP target
  • Start with a combination of 2 first-line agents of different classes
  • Can be either separate or fixed-dose combination

Treatment of white coat and masked hypertension (ACC/AHA)

• No data on the risks and benefits of treating white coat and masked hypertension
• Consistent evidence that masked hypertension and masked uncontrolled hypertension are associated with adverse outcomes related to elevated BP compared to normotensive individuals
• More recent evidence (see ‘Related ObG Topic’ below) that there may associated risk with white coat hypertension and research authors suggest lifestyle modification and monitoring to what for possible transition to sustained hypertension

Special Populations

During Pregnancy

• Transition to
  • Methyldopa | Nifedipine | Labetalol (see ‘Related ObG Entry’ below)
• Caution: Do not treat with
  • ACE inhibitors | ARBs | Direct renin inhibitors

Race / Ethnicity

• Black adults with hypertension but no heart failure or chronic kidney disease
  • Begin initial treatment with a thiazide-type diuretic or CCB
  • Target of <130/80 using two or more antihypertensives if needed is recommended for most adults, but “especially in black adults with hypertension”

Diabetic Patients with Hypertension

• Initiate treatment at ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg
• All first-line classes of antihypertensive are useful and effective
• “ACE inhibitors or ARBs may be considered in the presence of albuminuria”

Learn More – Primary Sources  

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association

ASCVD Heart Risk Calculator

Related ObG Topics: