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.