Red Flags
- BP ≥180/120 mmHg with chest pain, dyspnoea, neurological deficit, severe headache, or AKI — hypertensive emergency, immediate parenteral 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 maximally tolerated doses) — investigate secondary causes[1]
- New BP ≥160/100 in a previously normotensive patient under 30 — secondary cause workup[1]
First-line treatment
Interventions
- Lifestyle modification[1]Salt reduction <5 g/day, fruit-and-vegetable-rich diet, ≥150 minutes/week moderate aerobic activity, weight reduction if overweight, alcohol limitation, smoking cessation, stress management
- Opportunistic screening[1]Measure BP at every healthcare contact in adults ≥18; targeted community screening for adults >50, diabetics, obese, family history of hypertension
- Stepwise pharmacotherapy escalation[1]Start single agent for grade 1 HTN with low overall risk; dual therapy from outset for BP ≥160/100 or ≥20/10 above target; triple therapy if uncontrolled at 4–6 weeks
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Amlodipine[1] | Calcium channel blocker (DHP) | 5–10 mg PO once daily | — | First-line in IHCI primary-care workflow; widely available across PHCs and CHCs |
| Enalapril[1] | ACE inhibitor | 5–40 mg PO daily, divided BD if higher dose | — | Alternative first-line; switch to ARB if cough develops |
| Telmisartan[1] | Angiotensin receptor blocker (ARB) | 40–80 mg PO once daily | — | Preferred with diabetes, microalbuminuria, or chronic kidney disease |
| Hydrochlorothiazide[1] | Thiazide diuretic | 12.5–25 mg PO once daily | — | Combination partner with CCB or ACE-i/ARB; cost-effective |
Amlodipine[1]
Calcium channel blocker (DHP)
- Adult
- 5–10 mg PO once daily
- Paediatric
- —
First-line in IHCI primary-care workflow; widely available across PHCs and CHCs
Enalapril[1]
ACE inhibitor
- Adult
- 5–40 mg PO daily, divided BD if higher dose
- Paediatric
- —
Alternative first-line; switch to ARB if cough develops
Telmisartan[1]
Angiotensin receptor blocker (ARB)
- Adult
- 40–80 mg PO once daily
- Paediatric
- —
Preferred with diabetes, microalbuminuria, or chronic kidney disease
Hydrochlorothiazide[1]
Thiazide diuretic
- Adult
- 12.5–25 mg PO once daily
- Paediatric
- —
Combination partner with CCB or ACE-i/ARB; cost-effective
Safety-net
- Take medication every day even when feeling well — hypertension causes no symptoms 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 mmHg with end-organ involvementEmergency department for parenteral antihypertensive and end-organ workup[1]
- Resistant hypertension uncontrolled on 3 agents at maximally tolerated dosesCardiology or hypertension 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 bruitEndocrinology or nephrology for secondary cause workup[1]
Clinical summary
Primary-care management of hypertension per India's national Standard Treatment Guidelines, with opportunistic screening and stepwise pharmacotherapy.