Over time, hypertension guidelines have evolved, with earlier discussions centered mainly on recommendations from the Joint National Committee on Hypertension (JNC), including notable iterations such as JNC 6 (1998), JNC 7 (2004), and JNC 8 (2013). However, various other groups like the United States Preventive Services Task Force (USPSTF), American College of Cardiology (ACC), Department of Veterans Affairs (DoD), European Society of Hypertension (ESH), European Society of Cardiology (ESC), American College of Cardiology (ACC), and American Heart Association (AHA) have also contributed recommendations.

These guidelines differ in their definitions and thresholds for hypertension. For example, the ACC guidelines in 2017 established lower thresholds for hypertension diagnosis (120-129 mm Hg Systolic Blood Pressure (SBP) and < 80 mm Hg Diastolic Blood Pressure (DBP)). In contrast, the ISH and the Indian Society of Hypertension (InSH) guidelines are more aligned (130-139 mm Hg SBP and 85-89 mm Hg DBP), focusing on various stages of hypertension based on blood pressure ranges.

The management of hypertension, as emphasized by the ISH and ESH guidelines from 2023, prioritizes lifestyle interventions for Grade 1 hypertension (140-159 mm Hg SBP and 90-99 mm Hg DBP), progressing to combination drug therapies for Grade 2 hypertension (≥160 mm Hg SBP and ≥100 mm Hg DBP), and addressing hypertension-related organ damage.

Lifestyle modifications play a critical role in blood pressure management alongside medication. Attaining an ideal Body Mass Index (BMI) is crucial, with the optimal range between 18 and 22.9. Additionally, waist circumference measurements above 90 cm in men and 80 cm in women indicate obesity. They should be reduced for better health, while the waist-to-hip ratio should be below 0.9 for men and less than 0.85 for women.

Effective management of obesity involves crucial lifestyle modifications, such as dietary adjustments towards consuming more complex carbohydrates, proteins, and vegetables, coupled with moderate exercise. For example, individuals of average weight are advised to exercise at least 150 minutes per week or 30 minutes daily. In contrast, those with obesity should aim for at least 300 minutes per week or 60 minutes daily. 

Regarding pharmacotherapy for obesity, medications like ARBs, calcium channel blockers (CCB), and certain diuretics may be considered. However, caution is warranted when administering drugs like diuretics in individuals with diabetes due to potential effects on blood sugar levels and cholesterol. For severe cases of obesity with a BMI over 37 or morbid obesity, bariatric surgeries like gastric banding, gastrectomy, or gastric bypass may be recommended, as these procedures can significantly aid in weight loss and mitigate obesity-related health risks.

According to the InSH 2023 guidelines, monotherapy is recommended for Grade 1 hypertension, with suggested drugs including RAS inhibitors (RASi), CCBs, and diuretics. For Grade II hypertension, dual therapy with ARB and CCB or CCB with ACE inhibitors is advised. The ESH guidelines propose initial treatment for Grade 1 hypertension involving ACE inhibitors, ARB with CCB, or diuretics (a dual combination), with a potential upgrade to triple combination therapy if hypertension remains uncontrolled. 

In cases of resistant hypertension, a triple-drug combination along with spironolactone or other drugs is recommended. Beta-blockers (BB) should be considered when specifically indicated, such as in heart failure, post-MI, or in younger women planning for pregnancy/pregnancy.

In the general population, various common risk factors contribute to hypertension, and medications such as ARBs, beta-blockers, and diuretics are commonly prescribed to manage the condition effectively. However, prioritizing non-pharmacological treatments, such as dietary modifications, specific exercises (favoring isotonic over isometric exercises to avoid raising blood pressure), and lifestyle adjustments, including moderation in alcohol consumption, remains crucial.

Special attention must be given to specific patient groups, including those with coronary artery disease (CAD), diabetes mellitus (DM), chronic kidney disease (CKD), or during pregnancy. In individuals with diabetes, hypertension (HTN) occurs twice as frequently compared to the general population. Also, managing hypertension in conjunction with diabetes is crucial due to the higher prevalence of isolated systolic hypertension and increased cardiovascular risks in individuals with both conditions. Lifestyle measures, including reducing salt intake, maintaining a healthy weight, following a balanced diet rich in fruits and vegetables, regular exercise, and avoiding smoking and excessive alcohol consumption, are essential.

Pharmacotherapy is initiated if blood pressure exceeds 130/80 mm Hg, with ACE inhibitors (ACEi) or angiotensin receptor blockers (ARB) recommended in the presence of microalbuminuria. If blood pressure remains above target levels by 20/10 mm Hg, long-acting non-dihydropyridine CCB may be added, as they have shown efficacy in reducing albuminuria.

 In CAD, drug therapy typically includes ACE inhibitors, ARBs, BB, CCBs, statins, and nitrates in conjunction with lifestyle modifications. Similarly, for individuals with arterial fibrillation, common recommended medications are ACE inhibitors, ARBs, beta-blockers, and diuretics.

Detecting and managing hypertension-related organ damage is critical, even in cases of less severe hypertension. Patients with hypertension and comorbidities such as heart failure, CKD, or retinopathy require specialized investigations, including electrocardiography (ECG), echocardiography, carotid artery thickness measurements, and assessments of peripheral vascular function. Additionally, identifying and addressing factors that may contribute to or worsen hypertension, such as excessive sodium intake, smoking, alcohol consumption, caffeine, certain medications, and recreational drugs, is essential. 

During pregnancy, hypertension is classified into pre-existing hypertension, gestational hypertension, superimposed preeclampsia, and unclassified hypertension. Gestational hypertension typically arises after the 20th week of pregnancy and resolves within 42 days postpartum. Management of hypertension during pregnancy may involve drug therapy, which generally aligns with all four guidelines.

Moreover, emerging technologies such as telemedicine, mobile applications, artificial intelligence, and digital devices are increasingly leveraged to facilitate blood pressure management and monitoring. These advancements offer promising avenues in hypertension control, granting patients improved access to healthcare and personalized interventions.