Hypertension (HTN)

Audrey White

Definitions 

  • The AHA/ACC HBP 2025 guideline was updated with few differences to the 2017 guidelines, introducing several important changes in risk stratification, treatment approaches, and specific clinical scenarios 
  • ACC/AHA 2025: BP ≥ 130/80 or taking antihypertensive mediation 
  • Resistant HTN: uncontrolled BP despite taking 3 antihypertensive medications (including a diuretic) OR ≥ 4 total medications

Hypertension by ABPM/HBPM

Yes

No
Hypertension by office blood pressure Yes Sustained hypertension White coat hypertension
No Masked hypertension Sustained normotension

Screening 

  • Screen all adults >18. Less frequent screening (q3-5 yrs) is appropriate for adults 18-39 without risk factors and previously normal BP. More frequent screening (q6-12mo) for adults ≥40 or with risk factors (USPSTF Grade A) 
  • Risk factors: older age, black race, family history, excess weight/obesity, lifestyle habits (lack of physical activity, stress, tobacco use, alcohol use), dietary factors (high salt or high fat diet) 
  • Consider screening for masked HTN with ABPM/HBPM if SBP 120-129 mmHg in office + risk factors (ACC/AHA 2025) 
  • The 2025 guideline adopts the PREVENT equation for risk estimation, with >7.5% 10-yr CVD risk threshold

Diagnosis 

  • Proper measurement: Avoid caffeine/smoking 30 min prior and empty bladder. Have pt sit quietly at rest for 5 min with legs uncrossed. Place proper sized cuff on exposed arm, supported at heart level. 
  • Hypertension by office BP (≥130/80) and hypertension out of office confirmed by ABPM or HBPM, as follows: 
    • Daytime mean: SBP ≥ 130 or DBP ≥ 80 
    • Nighttime mean: SBP ≥ 110 or DBP ≥ 65 
    • 24 hr mean: SBP ≥ 125 or DBP ≥ 75 
    • If ABPM not possible, 2-3 outpt measurements at 1-4 week intervals are required to confirm diagnosis 
    • A diagnosis can be made without home readings if office SBP ≥ 160 or DBP ≥ 100

Evaluation 

  • Perform in all pts with newly diagnosed HTN 
    • BMP, fasting glucose, CBC, lipid profile, UA, TSH, EKG 
    • Calculate 10 yr PREVENT risk 
  • Distinguish between primary (90% incidence) vs. secondary HTN (10%) 
  • Suspect 1º (essential) HTN: gradual onset, family hx, associated risk factors 
  • Suspect 2º: unusual presentation = new diagnosis in young/elderly, abrupt, exacerbation in previously controlled HTN, drug-resistant, or the presence of clinical clue (see table) 
  • Assess for end organ damage: retinopathy (eye exam), CVD/LV hypertrophy, HF (TTE), CKD (urine Alb:Cr), PAD (ABI)

Common 2° Causes

Suggestive Features

Diagnostic Testing
Drug or alcohol induced History of substance use (cocaine, caffeine, nicotine, medications) UDS, BP improvement after withdrawal of suspected agent
Medication induced Steroids, OCP, sympathomimetic, SNRI/TCA, atypical antipsychotics BP improvement after withdrawal of suspected substance
OSA Apneic events, somnolence, obesity, ↑ neck circumference Polysomnography
Primary hyperaldosteronism Hypokalemia, metabolic alkalosis, Plasma aldosterone/renin levels

Should screen for in all patients with resistant HTN
Primary kidney disease Hypervolemia, ↑ Cr, abnormal UA, family history of kidney disease UA, urine Alb:Cr ratio, renal US
Renovascular disease (RAS or FMD) Abdominal bruit, ↑ Cr after ACE-I or ARB, young age, severe HTN with onset >55, flash pulmonary edema Doppler renal US
Uncommon 2° causes: Pheochromocytoma, Cushing's syndrome, thyroid dysfunction, aortic coarctation, primary hyperparathyroidism, acromegaly, congenital adrenal hyperplasia
* Not reliable if taking MRA. Adjust diagnostic threshold level if taking ACEi/ARB.

Management

ACC-AHA Guidelines (2025) (based on SPRINT trial)
Elevated BP SBP 120-129 mmHg AND DBP <80 mmHg Lifestyle modifications.
Reassess in 3-6 months
Stage 1 SBP 130-139 mmHg OR DBP 80-89 mmHg Lifestyle modification. If CVD, T2D, CKD, age ≥65 or ASCVD (PREVENT calculator) risk ≥7.5%, add anti-HTN medication.

If persistent after 3-6 mo of lifestyle modification, start anti-HTN medication.

Reassess monthly until BP goal is met, then measure q3-6 mo.
Stage 2 SBP ≥140 mmHg OR DBP ≥90 mmHg Lifestyle modification and 2 or more anti-HTN medications.
Reassess monthly until BP goal is met, then measure q3-6 mo.

Therapy Targets

  • AHA/ACC: <130/80 mmHg (encourage ideally SBP < 120 if high risk) 
  • AAFP: <140/90 (though lower targets may reduce MI risk) 
  • Consider higher target in frail pts with orthostatic hypotension, limited life expectancy

Non-pharmacological lifestyle interventions: indicated for all pts regardless of stage

  • 8-14 mmHg ↓: DASH diet (fresh produce, whole grains, low-fat dairy) 
  • 5-10 mmHg ↓: weight loss (10kg or 22lbs), expect 1 mmHg for every 1kg reduction in body weight 
  • 3-9 mmHg ↓: Na+ restriction (1.5g/d), aerobic exercise for 90-150 min/week, increased intake of K+ rich foods 
  • 2-4 mmHg ↓: moderate EtOH (2 drinks/day for men; 1 drink/day for women) 
  • Medication changes: consider transitioning offending medications 
  • Tobacco cessation: smoking increases risk of masked HTN, renovascular HTN, severe hypertensive retinopathy, and arterial stiffness

Pharmacologic therapy 

  • Initial monotherapy: ACEi/ARB, dihydropyridine CCB, or thiazides 
  • Combination therapy is often preferable to maximizing doses of single-agent. Preferred combinations include: ACEi / ARB + CCB; ACEi/ARB + CCB + thiazide; or ACEi / ARB + CCB + MRA 
  • Degree of BP reduction (not type of medication) is the major determinant of CVD risk reduction 
  • There is controversial evidence for considering race to determine therapy. Some studies suggest the benefit of CCB or thiazides in black pts

Drug Class

Common Drugs

Side effects/comments
Thiazide diuretics HCTZ 12.5-50 mg
Chlorthalidone 12.5-25 mg
(preferred agent based on RCT, but ↑ risk electrolyte abnormalities) 		HypoNa, hypoMg, hypoK, uric acid, hypovolemia, erectile dysfunction
Angiotensin-converting enzyme inhibitor (ACEI) Lisinopril, benazepril, fosinopril, quinapril (15-40 mg daily)
Ramipril 2.5-20 mg in 1-2 dose
Class 1 recommendation if phase CKD 		Contraindicated in pregnancy

Angioedema (more common in AA), AKI, hyperK, cough

Contraindicated in pregnancy
Angiotensin receptor blocker (ARB) Losartan 25-100 mg in 1-2 doses
Candesartan 8-32 mg in 1-2 doses

Irbesartan 150-300 mg
Valsartan 80-320 mg
Class 1 recommendation if phase CKD 		AKI, hyperkalemia, angioedema (less frequent than ACE-I), less ACE effect
Calcium channel blocker (CCB) Dihydropyridine:
Amlodipine 2.5-10 mg 1-2 doses
Nifedipine 30-120 mg in 1-2 dose

Nondihydropyridine:
Diltiazem ER 120-360 mg
Verapamil IR 100-480 mg 		Dihydropyridine: peripheral edema, worsens proteinuria
Nondihydropyridine: constipation, heart block if used with BB

Amlodipine is safe but not first line for HFREF. Offer CCB may worsen outcome in HFREF.
Mineralocorticoid receptor antagonist (MRA) Spironolactone 12.5-50 mg
Eplerenone 25-50 mg 		Good choice for resistant HTN
AKI, hyperkalemia
Spironolactone: gynecomastia and secondary sexual side effects

Need to hold prior to screening for hyperaldosteronism
Beta blocker (BB) Atenolol 25-100 mg in 1-2 doses
Carvedilol 6.25-25 mg BID
Metoprolol succinate 25-200 mg QD
Nebivolol 5-10 mg
Labetalol 100-300 bid 		CHF/CAD/arrhythmia
Hyperglycemia, fatigue, ↓ HR
Class 1 evidence (atenolol, bisoprolol, metoprolol) may be avoided in pt with COPD/asthma, diabetes
Vasodilators Hydralazine 25-100 mg in 2-4 doses
Minoxidil 5-10 mg in 3-4 doses 		Reserve for HTN resistant to optimized 4 drug regimen
Reflex tachycardia, fluid retention, SLE-like reaction
Centrally-acting agent (alpha 2 agonist) Clonidine 0.1-0.6 mg QD.
(Weekly transdermal patch 0.1-0.3 mg is preferred to avoid non-adherence and subsequent reflex HTN)

Methyldopa 250-500 mg QD 		Reserve for resistant HTN
Rebound HTN and withdrawal
Loop diuretics Furosemide 20-160 mg QD
Torsemide 10-100 mg QD
Bumetanide 0.5-5.0 mg QD 		Reserve for HTN and volume overload state
AKI, hypovolemia, hypoK

Conditions

Drug Class

Heart failureACE-I/ARB or ARNI + BB + MRA + diuretics
CADACEi/ARB or BB
DiabetesAll first line agents, ACEi/ARB if presence of albuminuria
CKDACEi/ARB
Recurrent stroke preventionACEi/ARB, thiazide
Pregnancynifedipine, labetalol, methyldopa

Additional information 

  • Refer to Nephrology or HTN specialist when HTN resistant to >3 meds and negative secondary work-up 
  • VA Specific Guidance: https://www.healthquality.va.gov/guidelines/CD/htn/ 
  • Agents that require PADR: quinapril, candesartan, irbesartan, olmesartan, telmisartan, labetalol, nebivolol, nifedipine SA, eplerenone, clonidine patch 
  • Walmart: $4/mo for atenolol, clonidine, furosemide, hydralazine, hydrochlorothiazide, indapamide, lisinopril-hctz, losartan-hctz, ramipril 
  • Validated BP cuffs: validatebp.org 
  • How to get BP cuff at the VA: Prosthetics consult BP Cuff TVHS. *Must answer all questions in the consult, including blood pressure cuff size
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