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]
Stage 2 HTN (≥160/100) in adult under 30 — workup for secondary cause^[1]

First-line treatment

Interventions

Single-pill fixed-dose combination^[1]
Initiate combination therapy from outset using single-pill formulations (e.g., amlodipine + telmisartan; amlodipine + losartan + HCTZ) — improves adherence, reduces therapeutic inertia, achieves earlier control
Lifestyle modification^[1]
Salt reduction <5 g/day, plant-based diet, ≥150 minutes/week moderate activity, weight reduction if overweight, alcohol moderation, smoking cessation
Team-based care and protocol-based titration^[1]
Non-physician health workers titrate per algorithm under physician supervision; monthly follow-up until target BP, then 3-monthly

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Amlodipine^[1]	Calcium channel blocker (DHP)	5 mg PO once daily, up-titrate to 10 mg if BP not at target after 4 weeks	—	First step in WHO HEARTS protocol; most countries initiate amlodipine alone or in combination
Telmisartan or enalapril^[1]	ARB or ACE inhibitor	Telmisartan 40–80 mg PO daily; enalapril 5–40 mg PO daily (divided BD if higher dose)	—	Second step partner with amlodipine; ACE-i / ARB choice based on availability and tolerance
Hydrochlorothiazide^[1]	Thiazide diuretic	12.5–25 mg PO once daily	—	Third agent when dual therapy insufficient; cost-effective and widely available
Spironolactone^[1]	Mineralocorticoid receptor antagonist	12.5–50 mg PO once daily	—	Fourth-line for resistant hypertension; monitor potassium and creatinine

Amlodipine^[1]

Calcium channel blocker (DHP)

Adult: 5 mg PO once daily, up-titrate to 10 mg if BP not at target after 4 weeks
Paediatric: —

First step in WHO HEARTS protocol; most countries initiate amlodipine alone or in combination

Telmisartan or enalapril^[1]

ARB or ACE inhibitor

Adult: Telmisartan 40–80 mg PO daily; enalapril 5–40 mg PO daily (divided BD if higher dose)
Paediatric: —

Second step partner with amlodipine; ACE-i / ARB choice based on availability and tolerance

Hydrochlorothiazide^[1]

Thiazide diuretic

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

Third agent when dual therapy insufficient; cost-effective and widely available

Spironolactone^[1]

Mineralocorticoid receptor antagonist

Adult: 12.5–50 mg PO once daily
Paediatric: —

Fourth-line for resistant hypertension; monitor potassium and creatinine

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; protocol-based care relies on consistent measurement and follow-up^[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]
Age <30 with new hypertension OR hypokalaemia OR abdominal bruitEndocrinology or nephrology for secondary cause workup^[1]

Clinical summary

Pharmacological treatment of hypertension per the WHO HEARTS technical package — protocol-based management for primary care in low- and middle-income settings.

References

1.2021 WHO Guideline for the Pharmacological Treatment of Hypertension in Adults; HEARTS Technical Package for Cardiovascular Disease Management (2021)