Nota Medik
Hypertension: Classification, BP Targets, Drug Choice, Escalation & Doses
Contents
Hypertension in one place: how to classify it, when to treat, what BP to aim for, which drug to pick, how to escalate and step down, and the usual doses. Based on the CPG Management of Hypertension (5th Edition, 2018). The diabetes section follows the newer CPG Management of T2DM (6th Edition, 2020).
Classification and diagnosis
| Classification | Systolic (mmHg) | Diastolic (mmHg) | |
|---|---|---|---|
| Optimal | <120 | and | <80 |
| Normal | 120-129 | and/or | 80-84 |
| At risk | 130-139 | and/or | 85-89 |
| Hypertension | |||
| Stage 1 (Mild) | 140-159 | and/or | 90-99 |
| Stage 2 (Moderate) | 160-179 | and/or | 100-109 |
| Stage 3 (Severe) | ≥180 | and/or | ≥110 |
| Isolated systolic hypertension | ≥140 | and | <90 |
Adapted from Table 1-A, CPG Hypertension 2018 (clinic BP in adults).
Home or ambulatory BP can be used to diagnose and stage hypertension:
| Category | Clinic BP (mmHg) | Home BP average or ABPM daytime average (mmHg) |
|---|---|---|
| Stage I hypertension | ≥140/90 | ≥135/85 |
| Stage II hypertension | ≥160/100 | ≥150/95 |
| Severe hypertension | SBP ≥180 or DBP ≥110 | - |
Remark: ABPM = ambulatory blood pressure monitoring; SBP/DBP = systolic/diastolic BP. Adapted from Table 1-B, CPG Hypertension 2018.
Risk stratification
Every patient is risk stratified: the global CV risk decides when to start drugs.
| BP levels (mmHg) | No RF, no TOD, no TOC | TOD or RF (1-2), no TOC | TOC or RF (≥3) or clinical atherosclerosis or CKD | Previous MI / IHD, previous stroke, or diabetes or CKD |
|---|---|---|---|---|
| SBP 130-139 and/or DBP 80-89 | Low | Intermediate | High | Very high |
| SBP 140-159 and/or DBP 90-99 | Low | Medium | High | Very high |
| SBP 160-179 and/or DBP 100-109 | Medium | High | Very high | Very high |
| SBP >180 and/or DBP >110 | High | Very high | Very high | Very high |
Remark: RF = additional risk factor (smoking, TC >6.5 mmol/L, family history of premature vascular disease); TOD = target organ damage (LVH, retinopathy, proteinuria); TOC = target organ complication (heart failure, renal failure); clinical atherosclerosis = CHD, carotid stenosis, peripheral vascular disease, TIA, stroke; MI = myocardial infarction; IHD = ischaemic heart disease; CKD = chronic kidney disease; SBP/DBP = systolic/diastolic BP; TC = total cholesterol; LVH = left ventricular hypertrophy.
| Risk level | Risk of major CV event in 10 years | Management |
|---|---|---|
| Low-intermediate | <10% | Healthy living |
| Medium | 10-20% | Drug treatment and healthy living |
| High | 20-30% | Drug treatment and healthy living |
| Very high | >30% | Drug treatment and healthy living |
Adapted from Table 3-D, CPG Hypertension 2018.
When to start drugs
- SBP 130-159 and/or DBP 80-99: assess global CV risk.
- Medium, high or very high risk → start drug treatment.
- Low-intermediate risk → healthy living with 3-6 monthly follow-up and reassessment of CV risk. If BP is still ≥140/90, start drugs; if <140/90, follow up 6-monthly.
- SBP ≥160 and/or DBP ≥100 → start drug treatment. Consider combination therapy (free or single-pill), except in older adults.
- Stage 1 with low CV risk: healthy living for 3-6 months first, seen at least twice (ideally monthly). Drugs haven't been shown to prevent CV outcomes in this group.
Healthy living for everyone: reduce salt, regular physical activity, limit alcohol to <2 drinks/day for those who drink, more dietary potassium (fruits, vegetables, nuts, legumes) and weight loss.
Adapted from Figure 5-A and Section 5.1a, CPG Hypertension 2018.
BP targets
| Patient group | Target BP (mmHg) |
|---|---|
| Most patients <80 years | <140/90 |
| High / very high CV risk | <130/80 |
| Age ≥80 years | <150/90 |
| Diabetes | See Hypertension in diabetes |
| CKD, proteinuria <1 g/24 h | <140/90 |
| CKD, proteinuria >1 g/24 h | <130/80 |
| LVH | <130/80 |
| IHD, PAD (with or without AF) | <140/90 |
| Stroke: primary prevention, and most secondary prevention | <140/90 |
| Lacunar stroke (secondary prevention) | <130/80 |
Remark: CKD = chronic kidney disease; LVH = left ventricular hypertrophy; IHD = ischaemic heart disease; PAD = peripheral arterial disease; AF = atrial fibrillation.
Older adults (Table 7.5-A): treat when SBP >160 mmHg.
| Older adult population | Target SBP (mmHg) |
|---|---|
| >80 years | <150 |
| 65-80 years | <140 (consider <130 if fit: free of conditions limiting mobility or function, good nutrition and cognition) |
| Multiple co-morbidities, functional or cognitive impairment, frail, institutionalised, or having ADRs | Consider less strict targets; limit the number of antihypertensives |
Remark: SBP = systolic BP; ADRs = adverse drug reactions.
- Bring BP to target within 3-6 months in high and very high risk patients.
- Once at target, follow up every 3-6 months, and at least 6-monthly, even when well controlled.
Choosing drugs
Uncomplicated hypertension, no compelling indication: first-line monotherapy is an ACEi, ARB, CCB or diuretic. All four reduce CV morbidity and mortality.
β-blockers are not recommended as first-line monotherapy here by some guidelines, but consider them in younger patients who:
- can't take ACEi/ARB (intolerance or contraindication), or
- are women of child-bearing potential, or
- have increased sympathetic drive.
β-blockers are also reasonable first line when there is a compelling need, e.g. post-MI or heart failure.
With a concomitant condition: pick by the grading below.
| Concomitant condition | Diuretics | β-blockers | ACEIs | CCBs | Peripheral α-blockers | ARBs |
|---|---|---|---|---|---|---|
| Diabetes mellitus (without nephropathy) | + | +/- | +++ | + | +/- | ++ |
| Diabetes mellitus (with nephropathy) | ++ | +/- | +++ | ++ | +/- | +++ |
| Gout | +/- | + | + | + | + | ++ |
| Dyslipidaemia | +/- | +/- | + | + | + | + |
| Coronary heart disease | + | +++ | +++ | ++ | + | +++ |
| Heart failure | +++ | +++# | +++ | +@ | + | +++ |
| Asthma | + | Contraindicated | + | + | + | + |
| Peripheral vascular disease | + | +/- | ++ | + | + | + |
| Non-diabetic renal impairment | ++ | + | +++ | ++ | + | ++ |
| Unilateral renal artery stenosis | + | + | ++$ | + | + | ++$ |
| Older adults with no co-morbid conditions | +++ | + | + | +++ | +/- | + |
| Very elderly (>80 years) with no co-morbid conditions | +++ | + | +++ | ++ | +/- | ++ |
Remark: ACEIs = ACE inhibitors; CCBs = calcium channel blockers; ARBs = angiotensin receptor blockers. Adapted from Table 5-C, CPG Hypertension 2018. + to +++ = increasing evidence and/or accepted practice; +/- = use with care. # Metoprolol, bisoprolol, carvedilol, nebivolol: titrate the dose gradually. @ Evidence for amlodipine and felodipine only. $ Contraindicated in bilateral renal artery stenosis.
Other compelling choices from the CPG:
- Post-MI: β-blocker, ACEi or ARB.
- HFrEF: β-blocker, ACEi and an aldosterone antagonist.
- LVH on ECG: ARB is the treatment of choice.
- PAD: any antihypertensive except a β-blocker as first choice; give an ACEi to prevent vascular events.
- Secondary stroke prevention: ACEi + diuretic is preferred.
- CKD with micro- or macroalbuminuria: start with a RAS blocker.
- Never combine an ACEi with an ARB (avoid dual RAS blockade).
Escalation
Stage 1: start low-dose monotherapy. If BP is still uncontrolled after up to 6 weeks, either:
- increase the dose of the first drug,
- switch to a drug from another class (if no response or not tolerated), or
- add a second drug.
Stage 2 and above: start with combination therapy. It can also be first line in high-risk stage 1, especially for secondary prevention. Single-pill combinations help adherence; a free combination is fine where cost matters.
| Preferred combinations (outcome-trial evidence) | Acceptable (no outcome evidence yet) |
|---|---|
|
|
Remark: ACEi = ACE inhibitor; ARB = angiotensin receptor blocker; CCB = calcium channel blocker; K⁺-sparing = potassium-sparing. Adapted from Table 5-B, CPG Hypertension 2018. An ACEi + dihydropyridine CCB is preferred over ACEi + thiazide in patients with high CV risk.
Resistant hypertension: BP >140/90 despite good adherence on 3 drugs including a diuretic (a RAS blocker, a CCB and a diuretic) at adequate doses.
- First check adherence, BP technique, office ("white coat") hypertension, and interfering drugs (NSAIDs, sympathomimetics, liquorice, oral contraceptives, corticosteroids).
- Confirm with home or ambulatory BP, then refer to exclude secondary causes (OSA and primary aldosteronism are common).
- Add spironolactone as the fourth drug.
Older adults: start cautiously with low-dose monotherapy, titrate slowly and review every 2-4 weeks at first. Combination therapy only after the first drug fails.
Refer for: severe hypertension (>180/110), suspected secondary hypertension, resistant hypertension, recent-onset target organ damage, pregnancy, office hypertension with added CV risk, age <30 years, and secondary prevention with multiple co-morbidities.
De-escalation
- Step-down is discouraged in the vast majority of patients; most stay on treatment life-long. If the patient insists, all of these must apply first:
- BP no higher than stage 1 (mild) hypertension with low global CV risk
- BP well controlled for at least 1 year on the same drugs at the same doses
- Agrees to follow-up at least 3-6 monthly
- Motivated to adopt healthy living
- ACEi/ARB: check creatinine and K⁺ before starting and within 2 weeks. Reduce or stop if K⁺ >5.6 mmol/L or creatinine rises persistently by >30% from baseline within 2 months.
- Older adults with ADRs such as postural hypotension and falls: consider de-prescribing. It doesn't increase mortality and cuts the pill burden.
Hypertension in diabetes
The T2DM CPG 2020 (newer than the Hypertension CPG) sets:
- Start drugs when BP is persistently ≥140 systolic and/or ≥90 diastolic. No CV benefit from treating 130-139/80-89.
- Target SBP 130-139 mmHg, DBP 70-79 mmHg.
- SBP <130 (if tolerated, but not <120) for patients without pre-existing CHD at higher risk of stroke or DKD.
- DBP not <70.
- ACEi or ARB first line (ARB if ACEi not tolerated); titrate to the maximum recommended dose for BP and anti-proteinuric effect. About 90% need 3 drugs; add a CCB or diuretic.
- Reduce or stop the ACEi/ARB if, within 2 months, creatinine stays ≥30% above baseline, eGFR falls ≥25%, or K⁺ is ≥5.6 mmol/L.
The Hypertension CPG 2018 gives <140/80 for diabetes (<130/80 in younger patients, <130/80 with CKD). The T2DM CPG 2020 figures above are the more recent ones.
Usual doses
Starting dose → recommended maximum daily dose (CPG Hypertension 2018, referenced from MIMS 2018).
| Drug | Starting dose | Maximum daily dose |
|---|---|---|
| ACE inhibitors | ||
| Captopril | 25 mg BD | 50 mg TDS |
| Enalapril | 10 mg OD | 40 mg daily |
| Lisinopril | 10 mg OD | 80 mg daily |
| Perindopril | 4 mg (erbumine) or 5 mg (arginine) OD | 8 mg (erbumine) or 10 mg (arginine) OD |
| Ramipril | 2.5 mg OD | 10 mg daily |
| Imidapril | 5 mg OD | 20 mg daily |
| Angiotensin receptor blockers | ||
| Candesartan | 8 mg OD | 32 mg OD |
| Irbesartan | 150 mg OD | 300 mg OD |
| Losartan | 50 mg OD | 100 mg OD |
| Telmisartan | 40 mg OD | 80 mg OD |
| Valsartan | 80 mg OD | 320 mg OD |
| Olmesartan | 20 mg OD | 40 mg OD |
| Calcium channel blockers: dihydropyridines | ||
| Amlodipine | 5 mg OD | 10 mg OD |
| Felodipine | 5 mg OD | 10 mg OD |
| Isradipine | 2.5 mg BD | 10 mg BD |
| Lercanidipine | 10 mg OD | 20 mg OD |
| Nifedipine | 5 mg TDS | 20 mg TDS |
| Calcium channel blockers: non-dihydropyridines | ||
| Diltiazem | 90 mg BD | 180 mg BD |
| Diltiazem SR | 100 mg OD | 200 mg OD |
| Verapamil | 80 mg TDS | 160 mg TDS |
| Verapamil SR | 120 mg OD | 480 mg OD |
| Diuretics | ||
| Hydrochlorothiazide | 12.5 mg OD | 25 mg OD |
| Amiloride/hydrochlorothiazide 5 mg/50 mg | 1 tablet OD | 1 tablet OD |
| Indapamide SR | 1.5 mg OD | 1.5 mg OD |
| β-blockers | ||
| Acebutolol | 200 mg BD | 1.2 g in divided doses |
| Atenolol | 50 mg OD | 100 mg OD |
| Betaxolol | 10 mg OD | 20 mg/day |
| Bisoprolol | 5 mg OD (CrCl <40: 2.5 mg/day) | 20 mg/day |
| Metoprolol | 50 mg BD | 200 mg BD |
| Nebivolol | 5 mg OD | 40 mg OD |
| Propranolol | 40 mg BD | 320 mg BD |
| α, β-blockers | ||
| Labetalol | 100 mg BD (elderly: 50 mg BD) | 2.4 g/day in 2-4 divided doses |
| Carvedilol | 12.5 mg OD | 50 mg OD, or in divided doses (HF/angina dosing differs) |
| Peripheral α-blockers | ||
| Doxazosin | 1 mg OD | 16 mg OD |
| Prazosin | 0.5 mg BD-TDS | 20 mg in divided doses |
| Terazosin | 1 mg ON | 20 mg OD |
| Centrally acting | ||
| α-methyldopa | 250 mg BD-TDS | 3000 mg daily |
| Clonidine (discouraged; never stop suddenly) | 50 mcg TDS | 2400 mcg daily |
| Moxonidine | 200 mcg OD; avoid if GFR <30 | 600 mcg in 2 divided doses; 400 mcg daily if GFR 30-60 |
Remark: OD = once daily; BD = twice daily; TDS = three times daily; ON = at night; SR = sustained release; CrCl = creatinine clearance; GFR in mL/min/1.73 m²; HF = heart failure. Adapted from Tables 9.1-A to 9.5-C, CPG Hypertension 2018. For doses in pregnancy, see chapter 7.6 of the CPG.
Sources
- Ministry of Health Malaysia, Malaysian Society of Hypertension, Academy of Medicine of Malaysia. Clinical Practice Guidelines: Management of Hypertension, 5th Edition. 2018. Tables 1-A, 1-B, 3-D, 5-B, 5-C, 7.5-A, 9.1-A to 9.5-C; Figure 5-A; Sections 5.1-5.4, 7, 10. MaHTAS
- Ministry of Health Malaysia. Clinical Practice Guidelines: Management of Type 2 Diabetes Mellitus, 6th Edition. 2020. Section 3.9.1 and Table 3-25 (hypertension in T2DM). MOH CPG - Endocrine