Essential hypertension

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

Cardiovasculaire risicobepaling in de eerste lijnPublished by: Domus MedicaLast published: 2020Évaluation du risque cardiovasculaire en première lignePublished by: Domus MedicaLast published: 2010

The main goal of treatment is to decrease the risk of mortality and of cardiovascular and renal morbidity.[3][80] [ ] [Evidence A] Treatment options include lifestyle modifications and antihypertensive drugs.

The American College of Cardiology (ACC)/American Heart Association (AHA) guideline recommends a blood pressure (BP) target of <130/80 mmHg for adults, regardless of age, with confirmed hypertension and known cardiovascular disease (CVD), or a 10-year atherosclerotic CVD risk (using the atherosclerotic CVD [ASCVD] risk estimator) of 10% or more.[2] [ ASCVD Risk Estimator Plus Opens in new window ] For adults with confirmed hypertension without additional markers of increased CVD risk, a BP target of <130/80 mmHg may be reasonable.

The European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guidelines recommend an initial treatment target of <140/90 mmHg in all patients (<140/80 mmHg in the 2023 ESH guideline). If treatment is well tolerated, the BP can then be targeted to 130/80 mmHg or lower in most patients.[1][63]

The World Health Organization (WHO) recommends a target BP of <140/90 mmHg in all patients with hypertension without comorbidities. In those with hypertension and known CVD or at high CVD risk, with diabetes, or with chronic kidney disease (CKD), the WHO recommends a target systolic BP <130mmHg.[4]

For a comparison of ACC/AHA and ESC targets and management, please see: US and European guidelines - classification and management Opens in new window

Evolving treatment goals

BP goals are evolving as more studies are being carried out.[81] The SPRINT trial (Systolic Blood Pressure Intervention Trial) ended early as it found that a lower systolic target of 120 mmHg (as measured by automated office blood pressure [AOBP]) reduced cardiovascular complications and deaths in people ages over 50 years with high BP and at least one additional risk factor for heart disease.[82][83][84] Patients with diabetes or stroke were excluded from the trial. However, in the HOPE-3 trial, intermediate-risk people without cardiovascular disease did not benefit from BP lowering unless in the highest tertile of starting BP (>143.5 mmHg) (as opposed to higher-risk patients in SPRINT).[85][86] The STEP trial was also ended early, as it found that patients ages 60-80 years with hypertension treated to a systolic BP target of 110 to <130 mmHg had a lower incidence of cardiovascular events (composite of stroke, acute coronary syndrome, acute decompensated heart failure, coronary revascularization, atrial fibrillation, or death from cardiovascular causes) than those treated to a target of 130 to <150 mmHg.[87] In the STEP trial, office BP was measured by trained staff, with home BP measurements also used as an adjunct. Patients with diabetes were included, though the benefit of intensive treatment was not seen in these patients; patients with prior stroke were not included. In the STEP trial, intensive treatment did not have a significant effect on cardiovascular or all-cause mortality.[87] Longer-term follow-up of the SPRINT trial found that after the trial ended, the beneficial effect on cardiovascular and all-cause mortality did not persist, noting the importance of consistent long-term control of hypertension beyond the trial protocols.[88]

Because of differences in the general health of older patients, the decision to treat should be on an individual basis, and BP lowering should be gradual and carefully monitored by the physician.[1][89] The SPRINT trial results showed equal benefit in people ages >75 years, regardless of frailty or walking speed.[90][91] Patients with orthostasis at enrollment, patients with dementia, and those resident in a nursing home were excluded from the trial. One systematic review found insufficient evidence regarding the benefits of hypertension treatment for frail people >80 years of age taking multiple medications, concluding that treatment should be individualized.[92] Older patients >80 years should not be denied treatment or have treatment withdrawn solely on the basis of age.[1]

One Cochrane review of treatment goals in people with hypertension and a history of cardiovascular disease (myocardial infarction, angina, stroke, peripheral vascular occlusive disease) concluded that there was no benefit in treating to lower BP targets (≤135/85 mmHg) compared with standard BP targets (≤140 mmHg to 160mmHg/90 mmHg to 100 mmHg) in terms of total and cardiovascular mortality or cardiovascular events.[93]

Regarding patients with comorbid diabetes mellitus, there is good-quality evidence from the ACCORD trial that very intensive BP lowering (targeting a systolic pressure <120 mmHg, as compared with targeting <140 mmHg) does not lessen risk (composite outcome: nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular cause) and may increase risk of adverse events.[94] One systematic review and meta-analysis found that intensive BP lowering (systolic BP <130 mmHg) was associated with reduced risk of major cardiovascular diseases in patients with type 2 diabetes; a target systolic BP <140 mmHg was associated with reduced all-cause death, though further reduction did not result in further benefits.[95] The American Diabetes Association (ADA) recommends that BP targets in people with diabetes and hypertension are individualized by assessing cardiovascular risk, potential adverse effects, and patient preference.[96] The ACC/AHA and the ADA both recommend a BP goal of <130/80 mmHg for patients with diabetes.[2][96]

Evidence from the ESPRIT and BPROAD trials indicate that intensive BP lowering in high-risk patients (targeting a systolic pressure <120 mmHg) significantly reduces the risk of major cardiovascular events, compared with standard targets (<140 mmHg). However, this approach may increase the risk of adverse events, including symptomatic hypotension and hyperkalemia.[97][98]

Lifestyle modification and CVD risk reduction

The initial approach to a newly diagnosed patient should include a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

The initial therapeutic measure should be lifelong lifestyle modification, which includes:[1][2][52][63][99][100][101]

Sodium reduction (optimal goal ≤1.5 g/day). Use of salt substitutes has demonstrated BP-mediated protective effects for major cardiovascular events and mortality.[59][60][102][103]
Potassium supplementation (3.5 to 5.0 g/day). Preferably by consumption of a potassium-rich diet unless contraindicated.
Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins).
Waist circumference <40 inches (<102 cm) for men and <35 inches (<88 cm) for women; weight loss to a BMI of about 25 kg/m².
Increased physical activity. At least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes per week, as tolerated or recommended by physician.
Limited alcohol consumption. ≤2 standard drinks (<20-30 g alcohol) per day in hypertensive men; ≤1 standard drink (<10-20 g alcohol) per day in hypertensive women. Total weekly alcohol consumption should not exceed 140 g for men and 80 g for women. There is evidence to suggest that the relationship between alcohol consumption and BP is direct and linear, with no threshold, particularly for systolic BP.[41]

Advice about lifestyle modification should be given upon diagnosis and should continue concurrently with all other therapeutic measures. Prior to initiation of an exercise program, patients should discuss a plan with their healthcare provider.

Obesity is a major risk factor for hypertension. In addition to lifestyle modifications for weight loss, antiobesity pharmacotherapy and metabolic surgery may be considered in select patients to treat obesity and prevent or attenuate hypertension.[104] See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidemia, is also recommended in adults with hypertension.[1][2][63] Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolemia and Hypertriglyceridemia.

Antihypertensive drugs

The main classes of antihypertensives include:[1][2]

Diuretics:
- Thiazide (or thiazide-like): e.g., hydrochlorothiazide, chlorthalidone, indapamide
ACE inhibitors: e.g., lisinopril, enalapril, benazepril, perindopril, ramipril
Angiotensin-II receptor antagonists: e.g., candesartan, irbesartan, losartan, azilsartan, telmisartan, valsartan
Calcium-channel blockers: e.g., amlodipine, felodipine, nifedipine, diltiazem
Beta-blockers: e.g., metoprolol, bisoprolol, carvedilol.

The examples of antihypertensive drugs listed above are common examples of drugs in each class only; other drugs are available. Some of these drugs are available in fixed-dose combination formulations. These single pill formulations simplify dosing regimens and improve adherence.[1][8][105]

Considerations for antihypertensive drug regimens in the presence of key comorbidities (CVD, diabetes, renal) are given in the sections below.

Beta-blockers are not generally recommended for first-line treatment of hypertension. However, they can be used as first-line, or at any step, when indicated as guideline-directed medical therapy, e.g., in the presence of comorbid chronic coronary disease, heart failure, or atrial fibrillation, or can be considered in the presence of other comorbid conditions where their use can be favorable.[2][63][106]

Calcium-channel blockers may cause peripheral edema that can lead to a diuretic being prescribed (prescribing cascade); however, diuretics are generally not indicated in this situation as the edema is not caused by fluid overload and unnecessary use of diuretics may lead to increased risk of adverse events.[107]

The Diuretic Comparison Project compared hydrochlorothiazide with chlorthalidone in patients ages 65 years or older; patients were already receiving hydrochlorothiazide and were randomized to either continue or switch to chlorthalidone. At a median follow-up of 2.4 years, there was no difference between the groups in the primary composite outcome of nonfatal myocardial infarction, stroke, heart failure resulting in hospitalization, urgent coronary revascularization for unstable angina, and non-cancer-related death.[108]

Initiating therapy for stage 1 hypertension

The ACC/AHA guideline defines stage 1 hypertension as BP 130-139/80-89 mmHg.[2] According to the 2024 ESC guidelines, office systolic BP of 120-139 mmHg and diastolic BP of 70-89 mmHg is defined as elevated BP.[1]

CVD risk assessment tools are used to guide initial approach to therapy and whether the patient should receive antihypertensive medication or can be managed with lifestyle modifications.[1][2][4] The ACC/AHA guideline recommends using the Pooled Cohort Equations to assess 10-year atherosclerotic CVD risk. [ ASCVD Risk Estimator Plus Opens in new window ] The PREVENT™ calculator is also available; this is a newer calculator from the AHA that estimates the 10- and 30-year risk of total CVD for people ages 30 years and older. [ PREVENT™ online calculator Opens in new window ]

The ACC/AHA guideline recommends that patients with stage 1 hypertension and assessed as at low risk of CVD (<10% 10-year atherosclerotic CVD risk) may initially be managed with lifestyle modifications and reassessment in 3-6 months to determine if pharmacologic therapy is necessary.[2][109] Most patients will require drug therapy to achieve target BP control.

For stage 1 hypertension, combination therapy or monotherapy where appropriate can be initiated.[2][110] [ ] The choice of antihypertensive agent is driven by efficacy, adverse-effect profile, and cost. The ACC/AHA guideline recommends initiating a single antihypertensive agent for patients with a 10-year atherosclerotic CVD risk ≥10% or known concomitant cardiovascular disease, diabetes, or CKD.[2] [ ASCVD Risk Estimator Plus Opens in new window ]

The ESC guideline states that adults with documented CVD, including asymptomatic atheromatous disease on imaging, heart failure, type 1 or 2 diabetes mellitus, moderate or severe CKD, hypertension-mediated organ damage, and familial hypercholesterolemia are automatically considered to be at high or very high CVD risk and do not need formal risk assessment.[1] For all other patients with hypertension, the ESC guideline recommends that 10-year CVD mortality risk is estimated using the SCORE system. ESC: SCORE2 and SCORE2-OP Opens in new window European guidelines recommend initiating antihypertensive treatment with a two-drug combination, preferably a single pill combination, with the exception of patients with elevated BP and a high cardiovascular risk or in frail older patients in whom initiating treatment with monotherapy may be appropriate.[1][63] In patients with elevated BP and a high cardiovascular risk only a small reduction in BP may be required to achieve the BP target, and in frail older patients baroreflex sensitivity is frequently impaired and the risk of hypotension is greater.[1] For lower-risk patients with grade 1 hypertension, the 2024 ESC guidelines advise that antihypertensive treatment should be initiated after 3 months if BP is not controlled by lifestyle interventions alone.[1]

If BP cannot be controlled with a single agent, a drug from a different class of antihypertensives is added.

Stage 1 hypertension: without CVD-related comorbidity or chronic renal disease, or with diabetes

A choice among four preferred classes of drugs is recommended for initial therapy.[1][2][111][112]

Thiazide (or thiazide-like) diuretics have been shown to be safe and efficacious first-line therapy.[113] Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Alternative first-line choices include ACE inhibitors, angiotensin-II receptor antagonists, or calcium-channel blockers, or a combination of two different drugs from these classes (excluding the combination of ACE inhibitors and angiotensin-II receptor antagonists; generally, when an ACE inhibitor would usually be chosen but is not tolerated, an angiotensin-II receptor antagonist can be substituted). [ ]

In the general black population, including those with comorbid diabetes, a thiazide (or thiazide-like) diuretic or a calcium-channel blocker is recommended as initial pharmacologic therapy.[1][2] The recommendation is derived from a prespecified subgroup analysis of black patients, 46% of whom had diabetes, in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).[114][115]Leenen FH, Nwachuku CE, Black HR, et al; Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Collaborative Research Group. Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Hypertension. 2006 Sep;48(3):374-84.

In patients with diabetes who have increased albumin excretion, ACE inhibitors or angiotensin-II receptor antagonists are recommended. The ALLHAT study showed that chlorthalidone, amlodipine, or lisinopril were co-equal for mild hypertension in type 2 diabetes.[114] ACE inhibitors are renoprotective, decreasing the progression of proteinuria in patients with diabetes.[116] Sleep-time BP is the most significant independent prognostic marker of cardiovascular events in diabetes.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have demonstrated BP-lowering effects and may be considered in patients with type 2 diabetes.[117] In trials, the SGLT2 inhibitors empaglifozin, dapagliflozin, and canagliflozin have been found to lower systolic and diastolic BP and cardiovascular risk in people with type 2 diabetes compared with placebo.[118][119][120][121][122][123][124] The glucagon-like peptide 1 (GLP-1) receptor antagonists liraglutide and semaglutide have also shown a beneficial effect on BP.[125][126] However, SGLT2 inhibitors and GLP-1 receptor antagonists are not specifically licensed for BP-lowering and therefore they can only be considered in the management of hypertension in patients with a comorbid condition, such as diabetes, for which they can be prescribed. See Diabetic cardiovascular disease.

Stage 2 hypertension

The ACC/AHA guideline defines stage 2 hypertension as BP ≥140/90 mmHg.[2] The ESH guidelines define this category of BP in three grades:[63]

Grade 1 hypertension BP 140-159/90-99 mmHg
Grade 2 hypertension 160-179/100-109 mmHg
Grade 3 hypertension ≥180 mmHg/110 mmHg

Patients presenting with stage 2 hypertension will require more than one drug for BP control. Therefore, the initiation of two concurrent antihypertensives of different classes is recommended.

The combination of a nondihydropyridine calcium-channel blocker with a beta-blocker should be avoided, because of an increased risk of high-degree atrioventricular block.

Comorbid chronic coronary disease (CCD)

Guidelines recommend a beta-blocker, ACE inhibitor, or angiotensin-II receptor antagonist for patients with CCD and hypertension.[1][2][127] Other drugs such as dihydropyridine calcium-channel blockers, thiazide diuretics, and/or aldosterone receptor antagonists (mineralocorticoid receptor antagonists) are added as required to further control hypertension.

A beta-blocker offers cardioprotective effects in patients with chronic artery disease (CAD), decreasing myocardial wall stress and lessening myocardial oxygen demand. ACE inhibitors have been shown in some trials to decrease cardiovascular events, while other studies have not demonstrated a benefit for ACE inhibitors in the setting of stable CAD with normal left ventricular function.[128][129][130]

Many patients with CCD also take nitrates, which act as an exogenous nitric oxide donor. Modest reductions in systolic BP can be observed, but the Food and Drug Administration has not approved the use of nitrates solely as antihypertensive therapy. See Chronic coronary disease.

Comorbid heart failure (HF)

Recommended medications for HF also lower BP; however, HF guidelines note that clinical trials assessing the impact of BP reduction on outcomes in patients with hypertension and HF are lacking and that the optimal BP goal and antihypertensive regimen are not known.[131][132]

Heart failure with reduced ejection fraction (HFrEF)

Treatment of HFrEF (left ventricular EF <40%) is similar in hypertensive and normotensive patients. For most patients with HFrEF, a combination of drugs from the following four medication classes should be started initially and continued long-term:[132]

Renin-angiotensin system inhibitors (angiotensin receptor-neprilysin inhibitor [ARNi], ACE inhibitor, or an angiotensin-II receptor antagonist)
Beta-blockers
Aldosterone receptor antagonists
SGLT2 inhibitors.

Patients who have signs of congestion and volume overload are also prescribed diuretics.

Additionally, the combination of hydralazine and a nitrate (e.g., isosorbide dinitrate/hydralazine) has been shown to be of benefit for black patients who have persistent symptoms despite receiving optimal medical therapy, as well as in all patients with HF who cannot receive ACE inhibitors, angiotensin-II receptor antagonists, or ARNi because of intolerance or contraindications.[131][132]

Nondihydropyridine calcium-channel blockers are not recommended for the treatment of hypertension in adults with HFrEF.[2]

For more information, see Heart failure with reduced ejection fraction.

Heart failure with preserved ejection fraction (HFpEF)

HFpEF is defined as symptoms and signs of HF, with left ventricular EF ≥50%.[133]

Diuretics should be used to control hypertension in patients with comorbid HFpEF who present with symptoms of volume overload.[2]

While optimal BP goal and antihypertensive regimens are not known for patients with HFpEF, the American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Society of America (HFSA) guideline for management of HF advises that ACE inhibitors, angiotensin-II receptor antagonists, aldosterone antagonists, and possibly ARNi could be first-line agents to control BP, given experience with their use in HFpEF trials.[131] Similarly, a 2023 expert consensus document from the ACC suggests that, in addition to diuretics, patients with hypertension and HFpEF can be treated with ARNis, angiotensin-II receptor antagonists, and aldosterone antagonists.[134]

SGLT2 inhibitors (which have demonstrated BP-lowering effects) are also now recommended in the US and European guidelines for all patients with HFpEF.[131][134][135] For more information, see Heart failure with preserved ejection fraction.

Comorbid left ventricular hypertrophy

ACE inhibition has proven beneficial across a myriad of cardiovascular disease states including CHF and left ventricular hypertrophy (LVH).[128][129] An angiotensin-II receptor antagonist is first choice for comorbid LVH. Angiotensin-II receptor antagonists have been shown to decrease morbidity and mortality in patients with hypertension and LVH.[136]

Comorbid renal disease

An ACE inhibitor is first choice for comorbid renal disease (CKD stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/day or ≥300 mg/g albumin-to-creatinine ratio or equivalent in the first morning void]).[2] If an ACE inhibitor is not tolerated, an angiotensin-II receptor antagonist can be used.[137]

Continuing ACE inhibitor or angiotensin-II receptor antagonist therapy may be associated with cardiovascular benefit as kidney function declines.[138]

Second-choice options are a calcium-channel blocker or a thiazide diuretic. In the CLICK trial, in patients with advanced CKD and poorly controlled hypertension, chlorthalidone therapy improved BP control at 12 weeks compared with placebo.[139][140] A nondihydropyridine calcium-channel blocker (i.e., diltiazem, verapamil) may be indicated if there is proteinuria.[141]

Spironolactone may further reduce proteinuria when added to an ACE inhibitor or angiotensin-II receptor antagonist, but also raises the risk of hyperkalemia.[142][143] Spironolactone is usually added to an ACE inhibitor, or angiotensin-II receptor antagonist, after a thiazide diuretic has been added to minimize hyperkalemia. Eplerenone can be used as an alternative.

The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) guideline for management of BP in CKD recommends that patients with CKD are treated to a target systolic BP <120 mmHg, specifying that this should be measured using standardized office BP measurement, preferably automated office BP.[137] The ACC/AHA guideline recommends treating patients with CKD to a target of <130/80 mmHg.[2]

SGLT2 inhibitors have demonstrated renal benefits, and dapagliflozin may be considered in patients with CKD (stages 2-4) with and without diabetes.[144][145][146][147] Use of SGLT2 inhibitors is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of <30 mL/minute/1.73 m². Finerenone, a nonsteroidal mineralocorticoid receptor antagonist, is approved for use in diabetic CKD and has also been shown to have BP-lowering effects.[148][149] SGLT2 inhibitors and finerenone are not specifically licensed for BP-lowering and should be used according to their approval for CKD treatment in addition to antihypertensive drug therapy.[63] For more information, see Chronic kidney disease. Data on combining finerenone and SGLT2-inhibitors are limited.

Some drugs should be used with caution in patients with renal impairment and a dose adjustment may be required. Some drugs may also be contraindicated in patients with renal impairment. Consultation with a nephrology specialist should be considered. See Chronic kidney disease.

Comorbid atrial fibrillation

First choice is a beta-blocker. Second choice is a nondihydropyridine calcium-channel blocker.

Evidence from post-hoc analyses suggests that angiotensin-II receptor antagonists and ACE inhibitors do not prevent the occurrence or the recurrence of atrial fibrillation.[150][151][152][153] However, more recent guidelines note that use of ACE inhibitors and angiotensin-II receptor antagonists may be effective in the prevention of atrial fibrillation.[2][154] More investigation is needed.

Recalcitrant (resistant) hypertension

Recalcitrant (resistant) hypertension is defined as above-goal elevated BP in a patient taking three antihypertensive agents (commonly including a long-acting calcium-channel blocker, an ACE inhibitor or angiotensin-II receptor antagonist, and a diuretic) at maximally tolerated doses.[63][79] Managing recalcitrant hypertension requires expertise. Frequently requiring multiple antihypertensive agents, patients must be observed and counseled regarding adverse effects, medication adherence, potential drug-drug interactions, and metabolic abnormalities. Infrequently, patients will require a screen for secondary causes of hypertension.

Representative agents of the main treatment class options, including ACE inhibitors, angiotensin-II receptor antagonists, and calcium-channel blockers, should be maximized. ACE inhibitors, angiotensin-II receptor antagonists, and/or direct renin inhibitors should not be used together due to the risk of acute renal failure. An optimally dosed thiazide-like diuretic, such as chlorthalidone or indapamide, should be used over hydrochlorothiazide.[79] In the CLICK trial, in patients with advanced CKD and poorly controlled hypertension, chlorthalidone therapy improved BP control at 12 weeks compared with placebo.[139][140]

The fourth-line drug option is generally spironolactone. Eplerenone can be used as an alternative. Spironolactone and eplerenone are contraindicated in patients with hyperkalemia. Caution should be used in patients with renal impairment; either a dose adjustment may be required, or the drug may be contraindicated depending on the severity of renal impairment, indication for use (i.e., hypertension versus heart failure), and local guidance. Concomitant administration with potassium-sparing diuretics is contraindicated.

Otherwise, a fourth- or fifth-line option is a peripheral adrenergic blocker. Hydralazine is a less-preferred option due to its twice-daily dose requirement and increased risk of edema with simultaneous calcium-channel blocker treatment. Minoxidil may rarely be indicated in patients with advanced CKD; however, its use requires some expertise in anticipating and managing adverse effects of fluid retention. Combined alpha- and beta-blockers (e.g., carvedilol, labetalol) are considerations. Additionally, physicians with expertise in managing difficult-to-control hypertension have had niche success using a combination of a dihydropyridine calcium-channel blocker plus a nondihydropyridine calcium-channel blocker (e.g., amlodipine plus diltiazem). Clonidine is generally avoided because of its adverse effect profile.

The most important principles for managing challenging hypertension are:

Promotion of medication adherence using the principle of pill reduction (i.e., use of single pill, fixed-dose combination formulations or avoidance of twice-daily dose regimens when possible)
Maximizing the dose of the diuretic (thiazide or thiazide-like)
Use of spironolactone or eplerenone as a fourth drug when possible.[155]

It is also important to question the patient's alcohol use and offer lifestyle counseling; structured diet and exercise programs can lower BP in patients with resistant hypertension.[156][157]

Referral to a specialist in hypertension should be considered.

Older adults

In the oldest adult patients, many physicians are reluctant to treat hypertension in accordance with usual BP goals, for a number of reasons, including concerns about fall risk, drug interactions, adverse effects, and lack of benefit in mortality reduction. Previous literature reviews and meta-analysis demonstrated reductions in stroke, heart failure, and cardiovascular events in much older adults without reaching mortality benefit.[158][159] However, the SPRINT trial found that treating ambulatory adults ages 75 years or older to a systolic BP target of <120 mmHg (as measured by AOBP) resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause, compared with a systolic BP target of <140 mmHg.[90] The STEP trial found that treating patients ages 60-80 years to a systolic BP target of 110 to <130 mmHg (measured by trained staff in office, with home BP measurements also used as an adjunct) had a lower incidence of cardiovascular events than those treated to a target of 130 to <150 mmHg, but intensive treatment did not have a significant effect on cardiovascular or all-cause mortality.[87] The SPRINT trial also found that intensive BP control did not result in any adverse effects on cognition: the risk of mild cognitive impairment and the combined rate of mild cognitive impairment or probable dementia was reduced in patients treated to a systolic BP target of <120 mmHg; however, the incidence of probable dementia was not reduced.[160] Patients with orthostasis at enrollment, patients with dementia, and those resident in a nursing home were excluded from the trial. One meta-analysis of randomized controlled trials (including SPRINT) found that pharmacologic treatment of hypertension in adults ages over 60 does not worsen cognition, and may reduce cognitive decline.[161] One Cochrane review assessing whether pharmacologic treatment of hypertension can prevent cognitive impairment or dementia in people who have no history of cerebrovascular disease found insufficient evidence.[162] Another meta-analysis found that BP reduction in patients in late-mid and later life reduced the risk of incident dementia compared with placebo.[163] One meta-analysis looking at the effects of intensive BP-lowering treatment on orthostatic hypotension found that intensive treatment of BP lowers risk of orthostatic hypotension (not raises it), and this finding was consistent regardless of age.[164] One meta-analysis comparing the effects of BP-lowering treatment on the risk of major cardiovascular events in groups of patients stratified by age and BP at baseline found that pharmacologic BP reduction was effective in older adults.[165]

One secondary analysis of randomized controlled trials (including SPRINT, STEP, and ACCORD) found that the benefit of intensive BP control in adults ages 60 years and over may be most appropriate in those with a life expectancy of more than 3 years, and that harms may outweigh benefits in those with a life expectancy of less than 1 year.[166]

The 2017 ACC/AHA guideline recommends a systolic BP goal of <130 mmHg for noninstitutionalized ambulatory community-dwelling adults. For older adults ≥65 years of age with hypertension, a high burden of comorbidity, and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs.[2]

European guidelines recommend a BP target of <140/90 mmHg in all patients including independent older patients and, if treatment is tolerated, a BP target of ≤130/80 mmHg in most patients.[1] UK guidelines from the National Institute for Health and Care Excellence recommend a BP target of <150/90 mmHg for patients ages 80 years and over.[67]

Pregnancy

Treatment described in this topic is for nonpregnant patients. Management in pregnancy should be referred to an obstetrician specializing in high-risk patients.

See Gestational hypertension.

Implementation success

High levels of hypertension control in large multi-ethnic populations has been demonstrated using basic principles of implementation science.[167][168][169] Core principles include:

A comprehensive hypertension registry
An evidence-based hypertension treatment algorithm based on single pill combination therapy
Free medical assistant visits for blood pressure measurement with follow-up triage, and
Team-based care
Performance reporting.

Given the large number of patients with hypertension and the use of protocol-based hypertension care delivery, team-based care incorporating nurses and clinical pharmacists is a key success factor.[170][171] In team-based care collaboration, generally the role of the clinical pharmacist involves medication choice and delivery, and the role of the nurse is patient education. One randomized controlled trial demonstrated the efficacy of a low-cost, nurse-led email reminder program across a spectrum of cardiovascular risk factors, including lipid improvement and BP reduction.[172]

The patient should be considered a hypertension team member. The TASMINH4 trial has shown that self-monitoring, with or without telemonitoring, used by general practitioners (primary care physicians) to titrate antihypertensive medication in patients with poorly controlled BP, leads to significantly lower BP compared with titration guided by office readings.[173]

An important goal is to continue to make efforts to improve disparities in BP control among people of different ancestries.[174]

Use of this content is subject to our disclaimer