From the Guidelines
The cornerstone treatment for patients with hypertension is upfront low-dose combination therapy, preferably with a single-pill combination of two major drug classes, including ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide or thiazide-like diuretics. This approach is recommended based on the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The guidelines suggest that combining drugs from different classes can have additive or synergistic effects, leading to greater blood pressure reduction and potentially fewer side effects.
Key Considerations
- The major four drug classes (ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide or thiazide-like diuretics) are recommended as first-line BP-lowering medications, either alone or in combination 1.
- An exception is the combination of two RAS blockers, which is not recommended 1.
- For most hypertensive patients, a single-pill combination, initially containing two of these major drug classes, and initially at low dose, is recommended 1.
- When blood pressure is still uncontrolled under maximally tolerated triple-combination therapy, the patient should be considered resistant and referred to an expert centre for appropriate work-up, and the addition of spironolactone or other mineralocorticoid receptor antagonists (MRAs) should be considered 1.
Additional Therapy
- If spironolactone is not tolerated, eplerenone or other MRAs, or beta-blockers (if not already indicated), should be considered 1.
- Eplerenone may need to be dosed higher (50–200 mg) for effective blood pressure lowering, and due to its shorter time of action than spironolactone, it may need to be administered twice daily for treating hypertension 1.
- A vasodilating beta-blocker (e.g., labetalol, carvedilol, or nebivolol) is preferred when a beta-blocker is chosen 1.
Lifestyle Modifications
While pharmacological therapy is a cornerstone, lifestyle modifications such as adopting the DASH diet, regular physical activity, weight reduction, limiting alcohol consumption, and smoking cessation are also essential components of hypertension management, as they can lower systolic blood pressure and enhance the effects of pharmacological 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. 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 cornerstone treatment for patients with hypertension is blood pressure reduction through various pharmacologic classes and lifestyle modifications, including:
- Lipid control
- Diabetes management
- Antithrombotic therapy
- Smoking cessation
- Exercise
- Limited sodium intake 2 3
From the Research
Cornerstone Treatment for Hypertension
The cornerstone treatment for patients with hypertension involves a combination of lifestyle modifications and pharmacological therapy.
- Lifestyle modifications include:
- Weight loss
- Healthy dietary pattern with low sodium and high potassium intake
- Physical activity
- Moderation or elimination of alcohol consumption
- Pharmacological therapy consists of:
- Thiazide or thiazide-like diuretics such as hydrochlorothiazide or chlorthalidone
- Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers such as enalapril or candesartan
- Calcium channel blockers such as amlodipine
Treatment Goals
The goal of treatment is to achieve a blood pressure target of less than 130/80 mm Hg for adults under 65 years and a systolic blood pressure of less than 130 mm Hg for adults 65 years and older 4.
Importance of Treatment
Treatment of hypertension is crucial as it reduces the risk of cardiovascular disease morbidity and mortality 4, 5, 6.
Effectiveness of Treatment
Randomized clinical trials have established the efficacy of blood pressure lowering to reduce the risk of cardiovascular disease events 4.
Implementation of Treatment
Implementation of multifaceted patient-centered treatment strategies for intensive blood pressure control can be effective in real-world clinical practice 7.