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.