Hypertension in Adults: Initial Evaluation and Management

Hypertension is a leading modifiable risk factor for cardiovascular disease and the most common chronic condition seen by family physicians. Treatment of hypertension reduces morbidity and mortality due to coronary artery disease, myocardial infarction, heart failure, stroke, and chronic kidney disease. The use of ambulatory and home blood pressure monitoring improves diagnostic accuracy. Assessment of adults with hypertension should focus on identifying complications of the condition and comorbid cardiovascular risk factors. Physicians should counsel all patients with elevated blood pressure about effective lifestyle interventions, including the Dietary Approaches to Stop Hypertension (DASH) diet, dietary sodium restriction, potassium enrichment, regular exercise, weight loss, and moderation of alcohol consumption. First-line antihypertensive medications include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics. Thresholds for pharmacologic intervention and blood pressure goals differ according to various guidelines. Evidence strongly supports reducing blood pressure to less than 140/90 mm Hg to reduce the risk of all-cause and cardiovascular mortality in adults with hypertension. Lowering blood pressure to less than 135/85 mm Hg may further reduce the risk of myocardial infarction. Clinical judgment and shared decision-making should guide treatment of patients with mild hypertension and older adults who may be more susceptible to adverse effects of antihypertensive medications and tight blood pressure control.