Hypertension Management
Targets, Drug Selection, and Special Populations
Hypertension Management
Part 1 — BP Classification and Treatment Thresholds
ACC/AHA 2017 classification applies to the average of ≥2 readings on ≥2 separate visits.
| Category | SBP (mmHg) | DBP (mmHg) | Initial Action |
|---|---|---|---|
| Normal | <120 | <80 | Encourage healthy habits; reassess in 1 year |
| Elevated | 120–129 | <80 | Lifestyle modification; reassess in 3–6 months |
| Stage 1 HTN | 130–139 | 80–89 | Lifestyle; add drug if ASCVD ≥10% or clinical CVD |
| Stage 2 HTN | ≥140 | ≥90 | Start two-drug combination + lifestyle |
| Hypertensive Crisis | ≥180 | ≥120 | See Part 3 |
Part 2 — Drug Selection
First-Line Agents (Class I, Level A — Whelton 2017; ALLHAT 2002)
Four classes are equally acceptable as first-line unless a compelling indication directs otherwise.
| Drug Class | Example Agent | Starting Dose | Notes |
|---|---|---|---|
| Thiazide diuretic | Chlorthalidone | 12.5–25 mg daily | Preferred over HCTZ (longer half-life, better 24-hr control; ALLHAT) |
| Dihydropyridine CCB | Amlodipine | 2.5–5 mg daily | Preferred in Black patients; CKD without proteinuria |
| ACE inhibitor | Lisinopril | 5–10 mg daily | CKD with albuminuria; HFrEF; diabetes |
| ARB | Losartan | 50 mg daily | Use when ACEi not tolerated; same indications |
Compelling Indication Table
| Condition | Preferred Drug(s) |
|---|---|
| CKD with albuminuria ≥300 mg/g | ACEi (first line) or ARB if ACEi not tolerated — renal protection (Class I) |
| Diabetes | ACEi or ARB preferred; CCB or thiazide acceptable add-on |
| HFrEF | ACEi/ARB + beta-blocker + MRA (GDMT treats HTN simultaneously) |
| Black patients (no CKD/HF) | Thiazide or DHP-CCB preferred (Class I, LOE A); ACEi/ARB less effective as monotherapy |
| Post-MI / stable CAD | Beta-blocker + ACEi/ARB |
| Pregnancy | Methyldopa, labetalol, or long-acting nifedipine — ACEi/ARBs absolutely contraindicated |
| eGFR <30 mL/min | Switch thiazide to loop diuretic (thiazides lose efficacy) |
When to Add a Second Agent
Adding a second drug reduces BP approximately 5 mmHg more than doubling the dose of the first agent.
- Stage 2 HTN at presentation: Start two drugs simultaneously (Class I)
- Stage 1 not at goal in 4–8 weeks: Add a complementary class (e.g., ACEi + thiazide, or CCB + ACEi)
- Never combine ACEi + ARB — Class III Harm: increased AKI and hyperkalemia with no CV benefit (ONTARGET)
Resistant Hypertension
Before adding a fourth drug: exclude pseudoresistance (non-adherence, white coat effect, wrong cuff size, volume overload from inadequate diuretic dose) and screen for secondary causes (OSA present in >50%, primary aldosteronism in 8–20%).
Fourth agent of choice: Spironolactone 25–50 mg daily (PATHWAY-2 trial — strongest evidence). Monitor potassium and creatinine within 1–2 weeks; use with caution if eGFR <45 or on ACEi/ARB.
Part 3 — Hypertensive Urgency vs. Emergency
| Hypertensive Urgency | Hypertensive Emergency | |
|---|---|---|
| BP | SBP ≥180 mmHg or DBP ≥120 mmHg | SBP ≥180 mmHg or DBP ≥120 mmHg |
| End-organ damage | Absent | Present |
| Symptoms | Headache, epistaxis, anxiety | Encephalopathy, chest pain (ACS), dyspnea (pulmonary edema), visual loss, focal neuro deficit, AKI |
| Setting | Outpatient; close follow-up 24–48 hrs | ICU; continuous monitoring |
| Treatment | Oral antihypertensives; gradual reduction over hours | IV labetalol or IV nicardipine; reduce MAP ≤25% in first hour |
| Goal | Lower BP over hours to days | Controlled, staged reduction — avoid overshoot |
Aortic dissection: Target SBP 100–120 mmHg immediately. Use IV labetalol or IV esmolol. Vasodilators alone cause reflex tachycardia and worsen aortic shear — beta-block first.
Target <130/80 mmHg for most patients. Start with lifestyle. If drug therapy is needed, thiazide, CCB, ACEi, and ARB are all acceptable first line unless a compelling indication directs otherwise. Resistant HTN means three drugs optimized and still uncontrolled — add spironolactone.
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