Hypertension is the most common modifiable cardiovascular risk factor. The clinical skill is confirming the diagnosis, choosing the right agent for the right patient, and identifying acute target-organ damage when BP is severely elevated — treat the patient, not the number.
CLINICAL PRINTABLE
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A one-page Hypertension Management clinical reference is on the way.
1 · Recognition / Diagnosis
- Diagnosis requires confirmed elevated readings on ≥2 occasions. White coat hypertension and masked hypertension are real — ambulatory blood pressure monitoring (ABPM) or home BP monitoring can clarify.
- Classify: Normal (<120/80), Elevated (120–129/<80), Stage 1 (130–139/80–89), Stage 2 (≥140/90). Severe hypertension vs hypertensive emergency is determined by the presence of acute target-organ damage, not BP number alone.
- Evaluate for secondary causes when: onset <30 years, resistant hypertension, abrupt onset, hypokalemia, abdominal bruit, or clinical features suggesting renovascular disease, primary aldosteronism, pheochromocytoma, or sleep apnea.
- Assess cardiovascular risk: 10-year ASCVD risk, diabetes, CKD, prior CVD, LVH, target organ damage. Risk guides treatment threshold and intensity.
2 · Treatment Pathway
Lifestyle modification
DASH diet, sodium restriction (<2.3 g/day), weight loss, aerobic exercise, alcohol moderation, smoking cessation. Lifestyle alone can lower BP 5–10 mmHg and should accompany all pharmacotherapy.
First-line agents
Thiazide/thiazide-like diuretics (chlorthalidone preferred over HCTZ), ACE inhibitors or ARBs, and dihydropyridine calcium channel blockers (amlodipine) are all first-line. Choice is guided by comorbidities.
Compelling indications
ACE/ARB: CKD with proteinuria, diabetes, HFrEF, post-MI. Beta-blocker: HFrEF, post-MI, angina, rate control. CCB: isolated systolic hypertension, angina, elderly. Aldosterone antagonist: resistant hypertension, HFrEF.
Combination therapy
Most patients with Stage 2 hypertension require ≥2 agents. ACE/ARB + CCB or ACE/ARB + thiazide are preferred combinations. Do not combine ACE inhibitor + ARB (dual RAAS blockade increases harm without additional benefit).
Resistant hypertension
BP above goal on ≥3 agents including a diuretic at optimal doses. Confirm adherence, white coat effect, and secondary causes before adding agents. Spironolactone is highly effective as a 4th agent.
3 · Expected Response / Monitoring
- Most antihypertensive agents reach full effect within 2–4 weeks. Recheck BP 4 weeks after initiation or dose change.
- Target BP <130/80 mmHg for most patients. Less aggressive targets may be appropriate in elderly patients with significant orthostatic hypotension risk.
- Monitor electrolytes and creatinine after initiating ACE/ARB or diuretics — especially in CKD.
4 · Escalation
- Hypertensive emergency: severely elevated BP with acute end-organ damage (hypertensive encephalopathy, aortic dissection, acute MI, acute HF, eclampsia, AKI). IV antihypertensives, ICU-level monitoring, controlled BP reduction.
- Severe hypertension without acute end-organ damage: oral agents, gradual reduction over 24–48 hours. No evidence that rapid reduction improves outcomes in otherwise stable patients.
- Nephrology or cardiology referral for resistant hypertension, suspected secondary hypertension, or significant target organ damage.
Apply It · Change One Detail
APPLY IT
A 55-year-old with BP 158/94 on two readings, diabetes, and microalbuminuria. Stage 2 hypertension with a compelling indication — ACE inhibitor or ARB is the preferred first agent for kidney and cardiovascular protection.
CHANGE ONE DETAIL
Change one detail — BP 178/110 with headache and blurry vision, creatinine rising from 0.9 to 2.1, and papilledema on fundoscopy. This is hypertensive emergency with acute end-organ damage — IV antihypertensives and ICU-level monitoring, not oral agents.
Bottom Line
Use 'severe hypertension' for markedly elevated BP without acute target-organ damage; hypertensive emergency requires severe BP elevation with acute target-organ damage. Treat the patient, not the number.
EVIDENCE & REFERENCES
- Whelton PK, et al. 2017 ACC/AHA Hypertension Guideline. J Am Coll Cardiol. 2018;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006
- SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015;373(22):2103-2116. doi:10.1056/NEJMoa1511939