Step-by-Step Treatment of Hypertension
Start all patients with lifestyle interventions immediately, and initiate drug therapy based on BP stage and risk factors, using a stepwise algorithm that differs by race and adjusts for chronic kidney disease. 1
Blood Pressure Classification and Initial Approach
Grade 1 Hypertension (140-159/90-99 mmHg)
Lifestyle interventions:
- Dietary sodium restriction to <5g sodium chloride per day 2
- Moderate-intensity physical activity for cumulative 150 minutes per week 3
- Weight reduction if overweight
Drug therapy timing:
- Start immediately if high-risk: CVD, CKD, diabetes, organ damage, or age 50-80 years 1
- Wait 3-6 months of lifestyle intervention if low-moderate risk with persistent BP elevation 1
Grade 2 Hypertension (≥160/100 mmHg)
Start drug treatment immediately along with lifestyle interventions 1
Drug Therapy Algorithm by Race
Non-Black Patients
Step 1: Low-dose ACE inhibitor or ARB 1
Step 2: Add DHP calcium channel blocker 1
Step 3: Increase to full doses 1
Step 4: Add thiazide or thiazide-like diuretic 1
Step 5: Add spironolactone; if not tolerated or contraindicated, use amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1
Black Patients
Step 1: Low-dose ARB + DHP-CCB OR DHP-CCB + thiazide/thiazide-like diuretic 1
Step 2: Increase to full doses 1
Step 3: Add diuretic or ARB/ACE inhibitor 1
Step 4: Add spironolactone; if not tolerated or contraindicated, use amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1
Important caveat: Consider monotherapy only in low-risk Grade 1 hypertension and in patients aged >80 years or frail 1. Simplify regimens with once-daily dosing and single-pill combinations 1.
Blood Pressure Targets
General Population
- Primary target: <130/80 mmHg 1
- Minimum acceptable: <140/90 mmHg 1
- Reduction goal: At least 20/10 mmHg 1
- Individualize for elderly based on frailty 1
Patients with Chronic Kidney Disease
Target BP: <130/80 mmHg 2
This lower target applies to all CKD patients regardless of proteinuria status, though the evidence is strongest for proteinuric disease.
Treatment of Hypertension with Chronic Kidney Disease
Initial Drug Selection Based on Proteinuria
Proteinuric CKD (urinary protein >500 mg/24h or ACR >30 mg/mmol):
First-line: ACE inhibitor (Grade A evidence) 2
- If ACE inhibitor not tolerated: ARB (Grade B evidence) 2
- Use highest approved tolerated dose to achieve proven benefits 3
Non-proteinuric CKD:
- RAS inhibitors (ACE inhibitor or ARB) are reasonable but not mandatory 3
Additional Agents for CKD
Second-line: Thiazide diuretics as additive therapy 2
- For CKD with volume overload: Loop diuretics are alternative 2
Third-line and beyond: Most patients require combination therapy with multiple agents to reach target BP 2
Critical Monitoring in CKD
Check within 2-4 weeks of RAS inhibitor initiation or dose increase:
- Blood pressure
- Serum creatinine
- Serum potassium 3
Continue ACE inhibitor/ARB unless:
- Serum creatinine rises >30% within 4 weeks 3
- Symptomatic hypotension occurs 3
- Uncontrolled hyperkalemia despite medical treatment 3
Hyperkalemia management: Often managed by measures to reduce serum potassium rather than stopping RAS inhibitor 3
What NOT to Do in CKD
Never combine ACE inhibitor + ARB + direct renin inhibitor (Grade B evidence) 3
Do not combine ACE inhibitor + ARB in non-proteinuric CKD (Grade B evidence) 2
Monitoring and Follow-Up
Achieve target BP within 3 months 1
If BP remains uncontrolled or other issues arise: Refer to provider with hypertension expertise 1
Common Pitfalls to Avoid
Precipitous BP lowering: Avoid rapid BP reduction, especially in acute settings; choose agents and routes carefully 2
Inadequate dosing: RAS inhibitors must be titrated to highest approved tolerated doses to achieve proven benefits 3
Premature discontinuation: Don't stop RAS inhibitors for mild creatinine elevation (<30% increase) or manageable hyperkalemia 3
Wrong diuretic choice: Use thiazide-like diuretics in most CKD; reserve loop diuretics for volume overload 2
Ignoring lifestyle interventions: Dietary sodium restriction improves BP control, especially with RAS blockade, but avoid in sodium-wasting nephropathy 3
Inappropriate salt substitutes: DASH diet and potassium-rich salt substitutes may cause hyperkalemia in advanced CKD or hyporeninemic hypoaldosteronism 3