Hypertension in adults

Red Flags

BP ≥180/120 mmHg with chest pain, dyspnoea, neurological deficit, severe headache, or AKI — hypertensive emergency, immediate parenteral therapy^[1]
Severe hypertension in pregnancy ≥20 weeks gestation with proteinuria, severe headache, visual symptoms, or epigastric pain — preeclampsia/eclampsia^[1]
Resistant hypertension uncontrolled on three agents at maximally tolerated doses including a diuretic — investigate secondary causes^[1]
Adverse effects climbing as BP target tightens — orthostasis, falls, syncope, AKI; reassess targets and de-prescribe where appropriate^[1]

First-line treatment

Interventions

Standard BP target <140/90 mmHg^[1]
Strong recommendation based on high-quality evidence: treating to <140/90 reduces all-cause and cardiovascular mortality as much as lower targets, with lower adverse effect burden
Optional lower target <135/85 mmHg via shared decision making^[1]
Weak recommendation: tighter target reduces myocardial infarction (NNT 137 over 3.7 years) but requires on average one additional medication; balance with the patient's values and adverse-effect tolerance
Lifestyle modification^[1]
Sodium reduction, DASH diet, weight loss if overweight, ≥150 min/week moderate aerobic activity, alcohol limitation, smoking cessation
Shared decision making after initial control^[1]
Once BP <140/90 achieved, discuss whether tighter target adds enough benefit to justify additional medication and side effects in this individual

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Hydrochlorothiazide or chlorthalidone^[1]	Thiazide / thiazide-like diuretic	12.5–25 mg PO once daily	—	First-line per AAFP; chlorthalidone has stronger trial evidence than hydrochlorothiazide
Lisinopril or enalapril^[1]	ACE inhibitor	Lisinopril 10–40 mg PO daily; enalapril 5–40 mg PO daily	—	First-line alternative; preferred with diabetes, CKD, or HFrEF
Amlodipine^[1]	Calcium channel blocker (DHP)	5–10 mg PO once daily	—	First-line alternative; preferred in older adults and isolated systolic hypertension

Hydrochlorothiazide or chlorthalidone^[1]

Thiazide / thiazide-like diuretic

Adult: 12.5–25 mg PO once daily
Paediatric: —

First-line per AAFP; chlorthalidone has stronger trial evidence than hydrochlorothiazide

Lisinopril or enalapril^[1]

ACE inhibitor

Adult: Lisinopril 10–40 mg PO daily; enalapril 5–40 mg PO daily
Paediatric: —

First-line alternative; preferred with diabetes, CKD, or HFrEF

Amlodipine^[1]

Calcium channel blocker (DHP)

Adult: 5–10 mg PO once daily
Paediatric: —

First-line alternative; preferred in older adults and isolated systolic hypertension

Safety-net

Take medication every day even when feeling well — hypertension is silent until target organs are damaged^[1]
Sudden severe headache, chest pain, vision changes, slurred speech, or one-sided weakness — call emergency services immediately^[1]
If you feel light-headed when standing or have unsteady balance — this may mean BP is being lowered too aggressively; report to your clinician^[1]

Referral criteria

BP ≥180/120 with end-organ involvementEmergency department for parenteral antihypertensive and end-organ workup^[1]
Resistant hypertension uncontrolled on 3 agents at maximum tolerated dosesHypertension or cardiology clinic for secondary cause workup^[1]
Pregnancy with BP ≥140/90 mmHgObstetric medicine same-day^[1]
Older adult with frequent falls or symptomatic orthostasis on antihypertensivesGeriatric medicine for medication review and de-prescribing assessment^[1]

Clinical summary

Family-medicine-focused blood pressure targets in adults with hypertension, weighing absolute risk reduction against treatment burden and adverse effects.

References

1.Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the American Academy of Family Physicians (2022) (2022)