Red Flags
- BP ≥180/120 mmHg with new neurological deficit, chest pain, dyspnoea, severe headache, or AKI — hypertensive emergency, immediate parenteral therapy[1]
- Severe hypertension (≥160/110) in pregnancy with proteinuria, severe headache, visual symptoms, or epigastric pain — preeclampsia/eclampsia[1]
- Resistant hypertension uncontrolled on ≥3 agents at maximally tolerated doses including a diuretic — investigate secondary causes[1]
- Stage 2 HTN (≥160/100) in young adult under 30 — workup for secondary cause[1]
First-line treatment
Interventions
- Single-pill combination[1]Two-agent fixed-dose combination preferred from initiation when BP ≥160/100 mmHg or ≥20/10 above target — improves adherence and time to control
- Lifestyle modification[1]Salt reduction <5 g/day, plant-based diet, ≥150 minutes/week moderate aerobic activity, weight reduction if overweight, alcohol moderation, smoking cessation
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Amlodipine[1] | Calcium channel blocker (DHP) | 5–10 mg PO once daily | — | Essential-level first-line; widely available globally; effective across age groups |
| Telmisartan or losartan[1] | Angiotensin receptor blocker (ARB) | Telmisartan 40–80 mg or losartan 50–100 mg PO once daily | — | First-line in diabetes, microalbuminuria, or chronic kidney disease |
| Hydrochlorothiazide[1] | Thiazide diuretic | 12.5–25 mg PO once daily | — | Essential-level diuretic; combination partner with CCB or ARB |
| Enalapril[1] | ACE inhibitor | 5–40 mg PO once or twice daily | — | Alternative to ARB; switch to ARB if dry cough develops |
Amlodipine[1]
Calcium channel blocker (DHP)
- Adult
- 5–10 mg PO once daily
- Paediatric
- —
Essential-level first-line; widely available globally; effective across age groups
Telmisartan or losartan[1]
Angiotensin receptor blocker (ARB)
- Adult
- Telmisartan 40–80 mg or losartan 50–100 mg PO once daily
- Paediatric
- —
First-line in diabetes, microalbuminuria, or chronic kidney disease
Hydrochlorothiazide[1]
Thiazide diuretic
- Adult
- 12.5–25 mg PO once daily
- Paediatric
- —
Essential-level diuretic; combination partner with CCB or ARB
Enalapril[1]
ACE inhibitor
- Adult
- 5–40 mg PO once or twice daily
- Paediatric
- —
Alternative to ARB; switch to ARB if dry 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 helps confirm control between clinic visits[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 including a diureticHypertension or cardiology clinic for secondary cause workup[1]
- Pregnancy with BP ≥140/90 mmHgObstetric 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
Resource-stratified hypertension management designed for global use, distinguishing essential (minimum) and optimal care recommendations.