Red Flags
- BP ≥180/120 mmHg with chest pain, dyspnoea, neurological deficit, severe headache, or AKI — hypertensive emergency, immediate IV therapy[1]
- BP ≥160/110 in pregnancy ≥20 weeks with proteinuria, severe headache, visual symptoms, or epigastric pain — preeclampsia/eclampsia[1]
- Resistant hypertension (uncontrolled on 3 agents including a diuretic at maximum tolerated doses) — secondary cause workup[1]
- New BP ≥160/100 in a previously normotensive patient under 30 — investigate for secondary cause[1]
First-line treatment
Interventions
- Lifestyle modification[1]Salt reduction <5 g/day, DASH-style diet, ≥150 minutes/week moderate aerobic activity, weight reduction if overweight, alcohol limitation, smoking cessation
- Dual therapy initiationThe May 2026 ICMR STW allows a two-class combination as default initial treatment for most adults and prefers single-pill combinations. Monotherapy remains appropriate for low-risk grade 1 hypertension, age ≥80 years, or frailty. [2]
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Amlodipine[1] | Calcium channel blocker (DHP) | 5–10 mg PO once daily | — | Preferred initial agent in IHCI primary-care workflow; effective across age groups including elderly |
| Telmisartan[1] | Angiotensin receptor blocker (ARB) | 40–80 mg PO once daily | — | Preferred with diabetes, microalbuminuria, or chronic kidney disease |
| Hydrochlorothiazide or chlorthalidone | Thiazide / thiazide-like diuretic | May 2026 ICMR STW: hydrochlorothiazide 12.5 mg once daily; chlorthalidone 12.5–25 mg once daily. [2] | — | Combination partner; chlorthalidone has stronger trial evidence than hydrochlorothiazide |
| Enalapril[1] | ACE inhibitor | 5–40 mg PO daily, divided BD if higher dose | — | Alternative to ARB; switch to ARB if cough develops |
Amlodipine[1]
Calcium channel blocker (DHP)
- Adult
- 5–10 mg PO once daily
- Paediatric
- —
Preferred initial agent in IHCI primary-care workflow; effective across age groups including elderly
Telmisartan[1]
Angiotensin receptor blocker (ARB)
- Adult
- 40–80 mg PO once daily
- Paediatric
- —
Preferred with diabetes, microalbuminuria, or chronic kidney disease
Hydrochlorothiazide or chlorthalidone
Thiazide / thiazide-like diuretic
- Adult
- May 2026 ICMR STW: hydrochlorothiazide 12.5 mg once daily; chlorthalidone 12.5–25 mg once daily. [2]
- Paediatric
- —
Combination partner; chlorthalidone has stronger trial evidence than hydrochlorothiazide
Enalapril[1]
ACE inhibitor
- Adult
- 5–40 mg PO daily, divided BD if higher dose
- Paediatric
- —
Alternative to ARB; switch to ARB if cough develops
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]
- Bring your BP record to every visit; home BP measurement (1 week, twice daily) helps detect white-coat hypertension and confirm control[1]
Referral criteria
- BP ≥180/120 mmHg with end-organ involvementEmergency department for IV antihypertensive and end-organ workup[1]
- Resistant hypertension uncontrolled on 3 agents including a diureticHypertension or cardiology clinic for secondary cause workup[1]
- Pregnancy with BP ≥140/90 mmHg, especially with proteinuria or symptomsObstetric medicine same-day[1]
- Age <30 with new hypertension OR hypokalaemia OR abdominal bruit OR abrupt onsetEndocrinology or nephrology for secondary cause workup[1]
Clinical summary
Diagnosis, evaluation, and pharmacological management of essential hypertension per Indian national guidance, with primary-care emphasis.