Hypertension

Use the American Heart Association (AHA) Home Blood Pressure Monitoring instructions to teach patients proper technique. Cuffless wearables should not determine diagnosis or medication titration.

• Use HBPM or ABPM to confirm sustained elevation and identify white-coat or masked patterns; ABPM also evaluates nighttime BP.
• Discordant readings: Recheck cuff fit, technique, timing, and recording adequacy. Measure orthostatic BP when symptoms or clinical risk warrant it.

• Baseline evaluation: Review cardiovascular disease (CVD), stroke, diabetes, CKD, pregnancy potential, and all medications. Obtain renal function, electrolytes, metabolic testing, urinalysis, urine albumin-to-creatinine ratio (UACR), and electrocardiogram (ECG).
• Predicting Risk of Cardiovascular Disease Events (PREVENT): For eligible adults without established CVD, use the PREVENT calculator’s 10-year total CVD estimate for stage 1 treatment decisions. Note that PREVENT atherosclerotic cardiovascular disease (PREVENT-ASCVD) is the estimate used for lipid decisions.
• Secondary causes: Evaluate clinical clues to primary aldosteronism, obstructive sleep apnea (OSA), renal disease, and other endocrine causes. Review use of nonsteroidal anti-inflammatory drugs (NSAIDs), stimulants, decongestants, glucocorticoids, and hormonal agents.
• Primary aldosteronism: Screen resistant HTN even without hypokalemia. Interpret aldosterone, renin, and the adosterone-to-renin ratio (ARR) in the context of potassium and interfering medications.Treatment

• Start medication: Average SBP ≥140 or DBP ≥90 mmHg; or SBP ≥130 or DBP ≥80 mmHg with CVD, prior stroke, diabetes, CKD, or PREVENT 10-year total CVD risk ≥7.5%.
• Lower-risk stage 1 HTN: Add medication if BP remains ≥130/80 mmHg after 3–6 months of lifestyle intervention.
• Target: Generally <130/80 mmHg, with encouragement toward SBP <120 mmHg when appropriate and tolerated, particularly with increased CVD risk. Individualize for frailty, limited life expectancy, institutional care, and tolerability; pregnancy and acute stroke require separate guidance.

The second and third agents usually come from the same first-line classes; comorbidities and tolerability determine the combination.

• Stage 1 requiring medication: Usually start one first-line agent.
• Stage 2: Start two complementary first-line agents, preferably in a single pill: an angiotensin-converting enzyme inhibitor (ACE inhibitor) or angiotensin II receptor blocker (ARB) plus a long-acting dihydropyridine calcium channel blocker (CCB) or thiazide-type diuretic.

• Above goal: Confirm home averages, adherence, tolerability, and effective dosing; add a complementary class. A usual three-drug foundation is an ACE inhibitor or ARB + dihydropyridine CCB + diuretic.
• Follow-up: Reassess generally monthly until controlled, using home averages and class-specific renal function and electrolyte monitoring.

BP above goal on three complementary drugs, including a diuretic at maximally tolerated doses—or control requiring four or more—suggests resistant HTN. Exclude measurement error, white-coat effect, nonadherence, and interfering substances before escalation.

• Preferred fourth drug when appropriate: Spironolactone, a mineralocorticoid receptor antagonist (MRA). Assess eGFR and potassium before and after initiation or titration; hyperkalemia or significant kidney dysfunction may preclude use.
• Further options: Seek specialist evaluation of secondary causes and individualized add-ons. Beta-blockers, alpha-blockers, central agents, and direct vasodilators have distinct indications and adverse effects.
• Aprocitentan: An add-on option for adults inadequately controlled on other drugs. Monitor fluid retention, anemia, and liver function; it is contraindicated in pregnancy.
• Renal denervation (RDN): An adjunct for selected patients after confirmation of uncontrolled HTN and optimization of care; refer for specialist evaluation.

• Albuminuric CKD: Favor an ACE inhibitor or ARB for kidney protection when indicated; diabetes alone does not require these classes.
• HF with reduced ejection fraction (HFrEF): Prioritize outcome-directed therapy: an angiotensin receptor–neprilysin inhibitor (ARNI) or ACE inhibitor/ARB, an evidence-based beta-blocker, MRA, and sodium-glucose cotransporter-2 inhibitor (SGLT2 inhibitor) as appropriate. Avoid nondihydropyridine CCBs.
• Angina, selected settings after myocardial infarction (MI), or rate control: A beta-blocker may be indicated earlier; it is not routine first-line therapy for uncomplicated HTN.
• Pregnancy or pregnancy planning: Use pregnancy-specific thresholds and drug selection; ACE inhibitors and ARBs are contraindicated in pregnancy.

• Acute target-organ injury: Requires monitored hospital management, often intravenous (IV) therapy. The affected organ and clinical syndrome determine the BP-lowering strategy.
• Without acute injury: Nonpregnant adults with SBP >180 or DBP >120 mmHg generally need timely oral therapy adjustment and follow-up. Avoid reflex rapid lowering of isolated asymptomatic inpatient readings.

Use lifestyle treatment across BP categories and alongside medication. Agree on specific goals, review progress with BP trends, and intensify support when the plan is not feasible.

• Diet and sodium: Use the Dietary Approaches to Stop Hypertension (DASH) eating plan. Target sodium <2,300 mg/day, moving toward 1,500 mg/day; focus on packaged and restaurant foods. Adapt food choices to preferences, budget, and available preparation facilities.
• Potassium: Favor potassium-rich foods when appropriate. Before recommending supplements or potassium-based salt substitutes, assess CKD, potassium levels, and medications that increase hyperkalemia risk.
• Weight and activity: For overweight or obesity, aim for at least 5% weight loss. Prescribe ≥150 minutes/week of moderate or ≥75 minutes/week of vigorous aerobic activity, plus resistance exercise; adapt to functional capacity.
• Alcohol and sleep: Recommend reducing or eliminating alcohol. Assess OSA when suggested by symptoms or resistant HTN; address sleep disruption and stress as part of the care plan.
• Total vascular risk: Address tobacco use, dyslipidemia, and diabetes alongside BP. Lifestyle counseling should not delay medication when treatment thresholds are met.

Uncontrolled BP can reflect cost, access, communication, and competing needs. Identify the barrier before labeling a patient nonadherent; pair the treatment decision with a practical response.

• Make monitoring accessible: Arrange a validated device and suitable cuff through coverage or a loan program. Confirm technique by demonstration; accept the AHA Blood Pressure Log or telephone reporting when digital access is limited.
• Make treatment sustainable: Ask about cost, refill access, transport, and work schedules. Use affordable once-daily regimens or single-pill combinations when covered; coordinate refills and delivery where available.
• Support understanding and follow-up: Use qualified interpreters and teach-back. Agree on how readings will reach the team, who will respond, and when BP and safety labs will be reviewed; offer flexible visit formats.
• Extend the care team: Use nurse/pharmacist titration protocols and community health workers for navigation, food-access referrals, and follow-up. Centers for Disease Control and Prevention (CDC) Team-Based Care guidance supports implementation.
• Measure where care falls short: Track control, intensification, missed follow-up, and device access by race/ethnicity, language, insurance, or geography when data permit. Use gaps to target resources and reassess results.

PREVENT calculator — select total CVD risk for hypertension decisions

AHA Home Blood Pressure Monitoring — measurement training

AHA Blood Pressure Log — serial home readings

NHLBI DASH Eating Plan — dietary counseling

2025 AHA/ACC multisociety High Blood Pressure Guideline — Jones DW, Ferdinand KC, Taler SJ, et al. JACC. 2025;86(18):1567–1678. doi:10.1016/j.jacc.2025.05.007

Aprocitentan prescribing information — revised August 2026

CDC High Blood Pressure Facts — prevalence and control estimates

AHA Measurement of Blood Pressure in Humans — 2019 scientific statement

AHA Resistant Hypertension — 2018 scientific statement

AHA Renal Denervation — 2024 scientific statement

AHA Elevated Blood Pressure in Acute Care — 2024 scientific statement

2022 AHA/ACC/HFSA Heart Failure Guideline — comorbidity-directed therapy

2023 AHA/ACC Chronic Coronary Disease Guideline — cardiac indications

AHA Physical Activity Recommendations — aerobic and resistance activity

CDC Team-Based Care — implementation and access barriers