Hypertension

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Overview

Intended use: Primary care
Summary of relevant guidelines and literature

Definitions

	Systolic		Diastolic
Normal	< 120 mm Hg	AND	< 80 mm Hg
Elevated	120 to 129 mm Hg	AND	< 80 mm Hg
Stage 1	130 to 139 mm Hg	OR	80 to 89 mm Hg
Stage 2	≥ 140 mm Hg	OR	≥ 90 mm Hg
Note: The phrase hypertensive urgency is no longer in use (asymptomatic elevated BP?) and PRN oral or IV antihypertensives should not be used to acutely lower blood pressure
See: Hypertensive Emergency

For hypertension in pregnancy, see:

Types:
Primary
White Coat
Masked
Secondary Hypertension (5-25% of patients!)

• suspect when stage 2, treatment resistant, sudden onset HTN
• DDx (common):
  • Obstructive Sleep Apnea (OSA) (25-50%)
  • primary aldosteronism (5-25%)
  • CKD (14%)
  • renal artery stenosis (0.1-5%)
  • medications/substances (2-20%)
    • alcohol
    • caffeine
    • decongestants (phenylephrine, etc)
    • herbals (st. johns wort, etc)
    • Black licorice
    • NSAIDs / APAP
    • recreational drugs / sympathomimetics
    • and many more

Workup

1. Recommend home/ambulatory monitoring after 1 in-office HTN reading
2. Diagnose and treat after:
   1. home confirmation
   2. 2 consecutive in-office HTN readings
   3. initial reading stage 2 or higher

Diagnostics:

• CBC
• BMP
• A1c
• Lipid Profile
• TSH
• UA
• Urine albumin-to-creatinine ratio; urine protein-to-creatinine ratio
• EKG
• IF STAGE 2 or suspected: serum aldosterone and renin
  • aldosterone-renin ratio >30
  • primary-aldosteronism.pdf
  • Patients should have unrestricted salt intake, serum potassium in the normal range (to avoid false-negative testing), and ideally, MRA (eg, spironolactone or eplerenone) withdrawn for at least 4 weeks before testing

Measurement

In-office: generally crap, if HTN suspected encourage ambulatory or home confirmation


Home:

• patient obtains two readings in the morning and two in the evening 3-7 days a week
• approved home devices: Validate BP

Treatment

Who to treat:
Stage 2 HTN: All patients
Stage 1 HTN + CVD, T2DM, CKD: All patients (use PREVENT™score to stratify)
Stage 1 HTN: 3-6mo lifestyle interventions, then medications
Elevated BP: Lifestyle

Goal BP:
minimum: <130 / <80
ideal: <120 / <80

Medications:
Pearls:

• Once daily dosing recommended
• stay at or below median dose

Favorites:

• ARB>ACEi
• olmesartan>other ARB
• chlorthalidone>HCTZ
• reserve BB for compelling indications (HF, prior MI, etc)

Options:
Stage 2 HTN: two antihypertensives, ideally fixed-dose combination pill
Stage 1 HTN: single antihypertensive
2 drug combos:

• ACEi + HCTZ
• ACEi + CCB
• ARB + HCTZ
• ARB + CCB
• ARB + BB
• BB + HCTZ

Compelling Indications:
CKD: ACEi / ARB
HFrEF: BB, MRA, ARNi/ARB/ACEi, SGLT2 (GDMT)
HFpEF: MRA, ARNi/ARB/ACEi

Lifestyle interventions:

• Exercise
• Zero alcohol
• Weight loss
• Dietary restriction
• Sodium restriction / Potassium increase (KCL salt)

Important References

2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM 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 Joint Committee on Clinical Practice Guidelines | Circulation

Efficacy and Safety of Quarter-Dose Blood Pressure–Lowering Agents | Hypertension

Effect of Salt Substitution on Cardiovascular Events and Death | New England Journal of Medicine

Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis - PubMed