What are the management strategies for Hypertension (High Blood Pressure)?

From the Guidelines

Management of hypertension requires a comprehensive approach combining lifestyle modifications and medication therapy, with the goal of achieving a blood pressure target of less than 130/80 mmHg, as recommended by the 2017 American College of Cardiology/American Heart Association guideline 1. The management plan should include the following components:

• Lifestyle modifications, such as:
  • Adoption of the DASH diet, which is rich in fruits, vegetables, and low-fat dairy products, and low in dietary cholesterol, saturated fat, and total fat 1
  • Sodium restriction to less than 2300mg daily
  • Regular physical activity, such as brisk walking for at least 30 minutes per day, most days of the week 1
  • Weight loss, if overweight or obese
  • Limiting alcohol consumption to no more than 1 oz (30 mL) of ethanol per day in most men and no more than 0.5 oz of ethanol per day in women and lighter weight persons 1
  • Smoking cessation
• Medication therapy, which should be initiated if lifestyle modifications are insufficient after 3-6 months or for patients with stage 2 hypertension (BP ≥140/90 mmHg), with first-line medications including:
  • Thiazide diuretics, such as chlorthalidone 12.5-25mg daily or hydrochlorothiazide 12.5-50mg daily
  • Calcium channel blockers, such as amlodipine 2.5-10mg daily
  • ACE inhibitors, such as lisinopril 10-40mg daily
  • ARBs, such as losartan 25-100mg daily
• Regular monitoring of blood pressure, preferably with home measurements, and periodic laboratory assessment of kidney function and electrolytes, especially when using diuretics, ACE inhibitors, or ARBs 1
• A team-based care approach, which may include the use of electronic health records, patient registries, and telehealth strategies to improve hypertension control and adherence to medication therapy 1

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits The largest and most consistent cardiovascular outcome benefit has been a reduction in the risk of stroke, but reductions in myocardial infarction and cardiovascular mortality also have been seen regularly Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal

The management of hypertension involves comprehensive cardiovascular risk management, including:

• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake It is recommended to follow published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 2 3. Antihypertensive drugs from different pharmacologic classes can reduce cardiovascular morbidity and mortality, with the largest benefit being a reduction in the risk of stroke. Patients with higher absolute risk, such as those with diabetes or hyperlipidemia, may benefit from more aggressive treatment to achieve a lower blood pressure goal.

From the Research

Management of Hypertension

• Hypertension is defined as persistent systolic blood pressure (SBP) at least 130 mm Hg or diastolic BP (DBP) at least 80 mm Hg, affecting approximately 116 million adults in the US and more than 1 billion adults worldwide 4.
• The condition is associated with increased risk of cardiovascular disease (CVD) events and death, making management crucial to reduce these risks.

Lifestyle Modifications

• First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 4, 5, 6, 7, 8.
• The Dietary Approaches to Stop Hypertension (DASH) diet, sodium restriction, and regular exercise are associated with improvements in blood pressure 5, 7.
• A healthy dietary pattern emphasizing vegetables, fruits, and whole grains, limiting sodium intake to less than 2,400 mg per day, and exercising three or four times per week for an average of 40 minutes per session is recommended 6.

Pharmacologic Therapy

• First-line drug therapy for hypertension consists of a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker 4, 5.
• The decision to initiate antihypertensive medication should be based on the level of BP and the presence of high atherosclerotic CVD risk 4.
• Thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers are the preferred medications in nonblack patients, while thiazide diuretics and calcium channel blockers are preferred in black patients 5.

Blood Pressure Targets

• The target blood pressure is less than 130/80 mm Hg for adults under 65 years and less than 130 mm Hg for adults 65 years and older 4.
• Reducing diastolic blood pressure to less than 90 mm Hg is beneficial in adults older than 30 years, and reducing systolic blood pressure to less than 150 mm Hg is beneficial in adults older than 60 years 5.
• A blood pressure goal of less than 140/90 mm Hg is recommended in patients with chronic kidney disease and in those with diabetes mellitus 5.