It is highly prevalent, affecting over 1 billion adults worldwide.
It is a leading modifiable risk factor for cardiovascular morbidity and mortality, including coronary artery disease, heart failure, stroke, and chronic kidney disease.
Accurate diagnosis requires proper BP measurement, with the use of averaged of multiple office readings and, when feasible, confirmation with ambulatory or home BP monitoring to exclude white coat and masked hypertension.
Initial assessment should include evaluation for secondary causes of hypertension, assessment of end-organ damage, such as left ventricular hypertrophy, retinopathy, nephropathy), and identification of comorbidities such as cardiovascular disease, chronic kidney disease, and diabetes.
Calculation of 10-year atherosclerotic cardiovascular disease (ASCVD) risk is recommended, to guide the intensity of management.
Lifestyle modification is the cornerstone of hypertension management and is recommended for all patients with elevated BP or hypertension.
Weight loss: Each 1 kg reduction in body weight is associated with a ~1 mm Hg decrease in SBP, with greater reductions are seen with more substantial weight loss.
Dietary Approaches to Stop Hypertension (DASH) diet: Emphasizes fruits, vegetables, whole grains, and low-fat dairy; can lower SBP by up to 11 mm Hg: Sodium reduction is the target.
Potassium enrichment: Aim for 3500–5000 mg/day through diet which can lower SBP by 4–5 mm Hg.
Physical activity: 90–150 minutes per week of aerobic exercise; expected SBP reduction of 4–8 mm Hg.
Alcohol moderation: Limit to ≤2 drinks/day for men and ≤1 drink/day for women; can reduce SBP by 4 mm Hg.
These interventions should be implemented in combination when possible.
Pharmacologic Therapy
Antihypertensive medication is indicated for patients with stage 2 hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg), those with stage 1 hypertension and a 10-year ASCVD risk ≥10%, or those with established CVD, CKD, or diabetes.
First-line agents include:
Thiazide or thiazide-like diuretics-chlorthalidone, hydrochlorothiazide.
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin receptor blockers (ARBs)
Calcium channel blockers (CCBs).
ACE inhibitors and ARBs should not be used in combination.
In patients with CKD, an ACE inhibitor or ARB is preferred for renal protection.
For most patients, starting with a single agent is appropriate, but in those with BP >20/10 mm Hg above target, initial combination therapy with two agents from different classes is recommended.
Single-pill combinations may improve adherence and BP control.