Blood Pressure Categories Hypertension Management

Systolic BP Diastolic BP Based on the 2017 ACC/AHA Guideline for the Prevention, Detection,
BP Category (mmHg) (mmHg) Evaluation, and Management of High Blood Pressure in Adults

Normal Blood Pressure <120 AND <80

Elevated Blood Pressure 120-129 AND <80 Hypertension Treatment Goals

Stage 1 Hypertension 130-139 OR 80-89 Goal for all ages <65 years with hypertension, regardless
of chronic comorbidities, if tolerated is <130/80 mmHg

Stage 2 Hypertension ≥140 OR ≥90

BP goal for ages ≥65 years is <130 mmHg (SBP)
Reasonable to adjust BP goal based on patient factors including: high
Use average of ≥2 BP readings obtained on ≥2 occasions comorbidity burden, life expectancy, clinical judgment, patient preference,
etc.

Hypertension Treatment Algorithm

Normal BP Elevated BP Stage 1 Hypertension Stage 2 Hypertension

<120/<80 mmHg 120-129/<80 mmHg SBP 130-139 or DBP 80-89 mmHg SBP ≥140 or DBP ≥90 mmHg

Promote healthy Nonpharmacological Clinical CVD, estimated Nonpharmacological

No
lifestyle habits interventions 10-year ASCVD risk of ≥10%? interventions
+
Drug treatment for
BP reduction
Nonpharmacological Nonpharmacological • Consider 2 agents from different drug
Reassess Annually Reassess in 3-6 months interventions interventions classes, especially if BP >20/10 mmHg
above goal
+
• Use first-line agents, those preferred
Drug treatment for for existing comorbidities, or based on
BP reduction tolerability
Antihypertensive Medications • Ideally use first-line agents, • Do not combine ACEi, ARB, or aliskiren
otherwise those preferred for Reassess in 3-6 months
existing comorbidities, or
Primary Medications (Generally First-Line) based on tolerability

Thiazide diuretics • Chlorthalidone preferred: long half-life, evidence for CVD benefit
e.g. chlorthalidone, indapamide • HCTZ: may be cheaper, more widely available, more tolerable
hydrochlorothiazide, metolazone • Monitor electrolytes: hyponatremia, hypokalemia, uric acid, calcium

ACE inhibitors • Do not combine with ARBs or aliskiren

e.g. lisinopril, benazepril, • Risk of hyperkalemia, esp. with CKD, K supplements, K-sparing drugs Reassess BP & adherence in
enalapril, ramipril, etc. • Avoid in pregnancy
1 month; assess tolerability
ARBs • Do not combine with ACEis or aliskiren Reassess BP & adherence in sooner as needed
e.g. losartan, valsartan, • Risk of hyperkalemia, esp. with CKD, K supplements, K-sparing drugs
• Avoid in pregnancy
1 month; assess tolerability
olmesartan, etc.
sooner as needed
CCBs, dihydropyridines • Dose-related lower leg edema, more common in females
e.g. amlodipine, felodipine, etc. • Avoid use with HFrEF; use amlodipine or felodipine if required

If BP is above goal
CCBs, non-dihydropyridines* • *Generally less preferred than the dihydropyridine CCBs
e.g. diltiazem, verapamil • Avoid regular use with BBs due to risk of bradycardia and heart block
• Do not use with HFrEF If BP is above goal • Titrate dose as tolerated
• Drug interactions: both are CYP3A4 substrates, moderate inhibitors
• If dosing is optimized then add
Secondary Medications • Titrate dose as tolerated additional drug; first use either
first-line agents, those preferred
Beta-blockers • May be first-line with compelling indication (e.g. IHD, post-MI, HF) • If dosing is optimized then add
for existing comorbidities, or
e.g. atenolol, metoprolol, carvedilol, • HFrEF preferred agents: metoprolol succinate, carvedilol, bisoprolol additional drug; first use either
bisoprolol, labetalol, nebivolol, etc. • Bronchospastic airway disease preferred: atenolol, metoprolol, bisoprolol based on tolerability
• Generally avoid use of BBs with intrinsic sympathomimetic activity first-line agents, those preferred
(e.g. acebutolol, pindolol, penbutolol), especially with IHD or HF for existing comorbidities, or • Do not combine ACEi, ARB, or
• Avoid abrupt cessation: risk of rebound tachycardia based on tolerability aliskiren
Loop diuretics • Preferred diuretics with symptomatic HF • Do not combine ACEi, ARB, or
furosemide, torsemide, bumetanide • Preferred over thiazides with significant CKD (GFR <30 mL/min)
aliskiren
K-sparing diuretics • Minimal antihypertensive effect; used to protect from hypokalemia
triamterene, amiloride • Avoid in patients with significant CKD (GFR <45 mL/min)

Aldosterone antagonists • Preferred add-on with resistant HTN and in primary aldosteronism
spironolactone, eplerenone • K-sparing diuretic effect: avoid with K-sparing diuretics, or CKD
• Spironolactone > risk of gynecomastia, impotence than eplerenone Reference: Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/
ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention,
Alpha-1 blockers • May be considered second-line in those with concomitant BPH Detection, Evaluation, and Management of High Blood Pressure in Adults: A
doxazosin, prazosin, terazosin • Risk for orthostatic hypotension, especially in older adults
Report of the American College of Cardiology/American Heart Association Task
• Use w/ a diuretic and BB: causes fluid retention and reflex tachycardia
Force on Clinical Practice Guidelines [published correction appears in J Am Coll
Direct vasodilators
hydralazine, minoxidil • Hydralazine has risk of drug-induced lupus-like syndrome Cardiol. 2018 May 15;71(19):2275-2279]. J Am Coll Cardiol.
• Minoxidil has risk of hirsutism and requires use with a loop diuretic 2018;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006

Central alpha-2 agonists • Generally last-line due to CNS adverse effects, orthostatic hypotension More clinical pearls at pyrls.com
clonidine, guanfacine, methyldopa • Avoid abrupt cessation: risk of rebound hypertension (esp. clonidine)
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