Outpatient management of essential hypertension: a review based on the latest clinical guidelines

Figures & data

Table 1. Classification of hypertension based on office blood pressure (BP) measurement.

Category	Systolic (mmHg)	and/or	Diastolic (mmHg)
American College of Cardiology/American Heart Association (2017)
Normal	<120	and	<80
Elevated	120–129	and	<80
Stage 1 Hypertension	130–139	or	80-89
Stage 2 Hypertension	≥140	or	≥90
European Society of Cardiology/European Society of Hypertension (2018)
Optimal	<120	and	<80
Normal	120–129	and/or	80-84
High-Normal	130–139	and/or	85-89
Grade 1 Hypertension	140–159	and/or	90-99
Grade 2 Hypertension	160–179	and/or	100-109
Grade 3 Hypertension	≥180	and/or	≥110
Isolated Systolic Hypertension	≥140	and	<90

Table 2. Blood pressure targets in hypertensive patients according to clinical conditions.

Patient Population	Systolic (mmHg)	Diastolic (mmHg)
American College of Cardiology/American Heart Association (2017)
All	<130	<80
European Society of Cardiology/European Society of Hypertension (2018)
Aged ≥65 years	130–139	70–79
Diabetes	Close to 130 (or lower if tolerated)	70–79
Coronary artery disease	Close to 130 (or lower if tolerated)	70–79
Chronic kidney disease	130–139	70–79
All others	120–129	70–79
Hypertension Canada (2020)
Low risk (no target organ damage or cardiovascular risk factors)	<140	<90
High risk of cardiovascular disease	<120	–
Diabetes mellitus	<130	<80
All others	<140	<90
World Health Organization (WHO 2021)
No comorbidities	<140	<90
Known cardiovascular disease	<130	–
High risk (diabetes mellitus, chronic kidney disease, high risk of cardiovascular disease)	<130	–

Table 3. Professional recommendations of physical activity for adults with hypertension.

	ACC/AHA 2017	ESC/ESH 2018	Hypertension Canada 2020
Frequency	–	5–7 days/week	4–7 days/week
Intensity	65%–75% heart rate reserve	Moderate	Moderate
Time	90–150 min/week	30 min/session	30-60 min/session
Type of training	Aerobic	Aerobic	Aerobic
Complementary training	Resistance training (90-–150 min/week; 50%–80% 1 rep maximum; 6 exercises, 3 sets/exercise, 10 repetitions/set)	Resistance training (2–3 days/week)	Resistance training (SBP/DBP of 140–159/90–99 mmHg)

Table 4. Blood pressure thresholds for initiation of antihypertensive therapy.

Patient Population	Systolic (mmHg)	Diastolic (mmHg)
American College of Cardiology/American Heart Association (2017)
High risk of cardiovascular disease	130–139	80–89
All others	≥140	≥90
European Society of Cardiology/European Society of Hypertension (2018)
Aged 18-79 years	≥140	≥90
Aged ≥80 years	≥160	≥90
Hypertension Canada (2020)
Low risk (no target organ damage or cardiovascular risk factors)	≥160	≥100
High risk of cardiovascular disease	≥130	–
Diabetes mellitus	≥130	≥80
All others	≥140	≥90
World Health Organization (2021)
No comorbidities	≥140	≥90
Known cardiovascular disease	≥130	–
High risk (diabetes mellitus, chronic kidney disease, high risk of cardiovascular disease)	130-139	–

Figure 1. General treatment algorithm for patients with high blood pressure and no compelling indications.

Table 5. Summary of first-line antihypertensive agents.

Name	Starting (mg/day)	Maintenance (mg/day)	Maximum (mg/day)	Additional Information	Taken with food?
Thiazide Diuretics
Bendroflumethiazide	5	5	5	–	No
Chlorothiazide	500–1000	500–1500	2000	May be given in 1–2 divided doses	No
Chlorthalidone	12.5–25	12.5–100	100	Doses above 50 mg/day are rarely used	Yes
Hydrochlorothiazide	12.5 (if taken with other antihypertensives) or 25	25–50	50	May be given in 1–2 divided doses; Doses above 50 mg/day are rarely used	No
Indapamide	1.25	1.25–5	5	-	No
Metolazone	2.5–5	2.5–5	20	-	No
Loop Diuretics
Bumetanide	0.5–2	-	10	2^nd and 3^rd dose may be given at intervals of 4 − 5 h up to max of 10 mg/day	No
Furosemide	40 BID	20–80	80	Decreased absorption when taken with food	Take on an empty stomach
Torsemide	5	5–10	10	-	No
Angiotensin-Converting Enzyme Inhibitors
Benazepril	5 (if taken with a diuretic) or 10	20–40	80	May give in 1–2 divided doses	No
Captopril	25 BID-TID	25–150 BID-TID	450	Increase dose at 1–2-week intervals	1 h before meals
Enalapril	2.5 (if taken with a diuretic) or 5	10–40	40	May give in 1–2 divided doses	No
Fosinopril	10	20–40	80	May give in 1–2 divided doses	No
Lisinopril	10	20–40	40	Lower starting doses in patients taking diuretics	No
Moexipril	7.5	7.5–30	60	Lower starting doses in patients taking diuretics; May give in 1–2 divided doses	1 h before meals
Perindopril	4	4–8	16	Lower starting doses in patients taking diuretics or elderly;  May give in 1–2 divided doses	No
Quinapril	10-20	20–80	80	Lower starting doses in patients taking diuretics; May give in 1–2 divided doses	No
Ramipril	2.5	2.5–20	20	May give in 1–2 divided doses	No
Trandolapril	1 (nonblack)  2 (black)	2–4	8	Lower starting doses in patients taking diuretics; May give in 1–2 divided doses	No
Angiotensin II Receptor Blockers
Azilsartan	40–80	40–80	80	Lower starting dose in patients taking diuretics	No
Candesartan	8–16	8–32	32	Lower starting dose in patients taking diuretics; May be given in 1-2 divided doses	No
Irbesartan	150	150–300	300	Lower starting dose in patients taking diuretics	No
Losartan	50	25–100	100	Lower starting dose in patients taking diuretics; May take 3-6 weeks for max effect	No
Olmesartan	20	20–40	40	Lower starting dose in patients taking diuretics	No
Telmisartan	40	20–80	80	Lower starting dose in patients taking diuretics;	No
Valsartan	80–160	80–320	320	Lower starting dose in patients taking diuretics	No
Dihydropyridine Calcium Channel Blockers
Amlodipine	2.5 (fragile, elderly, or hepatic insufficiency) or 5	5–10	10	Increase dose at intervals of 7–14 days	No
Felodipine	2.5 (elderly or liver disease) or 5	2.5–10	10	Do not crush, cut, or chew tablet	Take without food or a light meal
Isradipine	2.5 BID	2.5–10 BID	10 BID	Increase dose in increments of 5 mg/day at 2–4 week intervals. Max response seen in 2–4 weeks	No
Nicardipine	20 TID	20–40 TID	40 TID	Increase dose at intervals of ≥ 3 days	No
Nifedipine ER	30	30–60	120	Titrate dose over 7–14 days; Do not cut, crush, or divide tablet	Take on empty stomach; Do not take with grapefruit juice
Nisoldipine ER	17–20	17–40	40	Increase dose at intervals of ≥ 1 week; Do not cut, crush, or divide tablet	Take on empty stomach; Do not take with grapefruit juice
Lercanidipine	10	10	20	–	Take at least 15 min before food
Non-Dihydropyridine Calcium Channel Blockers
Diltiazem ER	120–240	240–360	360	Increase dose at 14 day intervals; available in capsule or tablet; do not crush, cut, or chew	Can take with or without food
Verapamil IR	40 TID (elderly or small patients) or 80 TID	80–120 TID	360	Blood pressure effect seen within first week of therapy	No
Verapamil ER	120 (elderly or small patients)  or 180	180–480	480	Blood pressure effect seen within first week of therapy; Daily doses > 240 mg should be given in 2 divided dose	Yes – capsule can be opened and sprinkled on applesauce
Beta-Blockers
Atenolol	50	50–100	100	Increase dose at intervals of 1–2 weeks	No
Bisoprolol	5	5–20	20		No
Carvedilol IR	6.25 BID	6.25–25 BID	25 BID	Increase dose at 7–14 days	Yes
Carvedilol ER	20	20–80	80	Increase dose at 7–14 days; Capsule may be opened and sprinkled over applesauce	Yes
Labetalol	100 BID	200–400 BID	1200–2400	Increase dose in increments of 100 mg/dose at intervals of 2–3 days	Yes
Metoprolol Succinate ER	25–100	100-400	400	Increase dose at intervals of 1 week	Yes
Metoprolol Tartrate IR	100	100–450	450	May give in 1–2 divided doses; increase dose at intervals of 1 week	Yes
Nadolol	40	40–80	320	-	No
Nebivolol	5	5–40	40	Increase dose at intervals of 2 weeks	No
Pindolol	5 BID	5–30 BID	60	Increase dose in increments of 10 mg/day every 2–4 weeks	No
Propranolol IR	40 BID	60–120 BID	640	-	No
Propranolol ER (Inderal LA)	80	120–160	640	Capsule, extended release	No
Propranolol ER (Innopran XL)	80 qHS	80–120 qHS	120	Capsule, extended release; Take consistently either on an empty stomach or with food	Yes or No
Timolol	10 BID	10–20 BID	30 BID	Increase dose at intervals of ≥ 7 days	No

Table 6. Summary of antihypertensive agents used in pregnancy.

Drug	Class	Dose	FDA Risk	Additional Information
First-line agents
Methyldopa	Central alpha agonist	500–3000 mg/day in 2 divided doses	B	Drug of choice according to National High Blood Pressure Education Program
Labetalol	Combined alpha and beta blocker	200–1200 mg/day in 2–3 divided doses	C	May be associated with fetal growth restriction
Long acting Nifedipine	Calcium channel blocker	30–120 mg/day	C	May inhibit labor and have synergistic BP-lowering action with magnesium
Second-line agents
Clonidine	Central alpha agonist	0.1–0.6 mg/day in 2 divided doses	C	Similar efficacy to methyldopa
Hydralazine	Peripheral vasodilator	50–300 mg/day in 2–4 divided doses	C	Useful in combination with sympatholytic agent; may cause neonatal thrombocytopenia
Hydrochlorothiazide	Thiazide diuretic	12.5–25 mg/day	C	May cause volume contraction and electrolyte abnormalities; May be useful in combination with methyldopa and vasodilator to mitigate compensatory fluid retention

Code availability

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Data availability statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.