What is the appropriate management for stable outpatients (outpatient) with manageable conditions, such as hypertension (high blood pressure)?

From the Guidelines

Stable outpatients with hypertension should be managed with a combination of lifestyle modifications and medication therapy, aiming for a blood pressure target of less than 130/80 mmHg, as recommended by the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. The management approach should prioritize lifestyle modifications, including sodium restriction, regular physical activity, weight management, limited alcohol consumption, and a diet rich in fruits, vegetables, and low-fat dairy products.

• Key lifestyle modifications include:
  • Sodium restriction to less than 2.3g daily
  • Regular physical activity of at least 150 minutes of moderate-intensity exercise weekly
  • Weight management to achieve a healthy body mass index
  • Limited alcohol consumption
  • A diet rich in fruits, vegetables, and low-fat dairy products For patients with uncomplicated hypertension, first-line medications include thiazide diuretics, ACE inhibitors, angiotensin receptor blockers, or calcium channel blockers.
• First-line medication options include:
  • Thiazide diuretics, such as hydrochlorothiazide 12.5-25mg daily
  • ACE inhibitors, such as lisinopril 10-40mg daily
  • Angiotensin receptor blockers, such as losartan 25-100mg daily
  • Calcium channel blockers, such as amlodipine 5-10mg daily Treatment should begin with a single agent at a low dose, with follow-up in 2-4 weeks to assess efficacy and side effects. If blood pressure remains above target, the dose can be increased or a second agent from a different class added, as recommended by the American Heart Association and the American Diabetes Association 1. Regular monitoring is essential, with home blood pressure measurements encouraged and clinic visits scheduled every 3-6 months for stable patients.
• Regular monitoring should include:
  • Home blood pressure measurements
  • Clinic visits scheduled every 3-6 months for stable patients These approaches work by addressing different physiological mechanisms of blood pressure regulation, including fluid volume, vascular resistance, and neurohormonal pathways, providing comprehensive control of hypertension while minimizing adverse effects, as supported by the 2018 synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline 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 one 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)

The appropriate management for stable outpatients with manageable conditions, such as hypertension, includes:

• Comprehensive cardiovascular risk management
• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake
• Using more than one drug to achieve blood pressure goals, as necessary 2
• Following 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

From the Research

Management of Stable Outpatients with Hypertension

The management of stable outpatients with hypertension involves the use of various antihypertensive agents to achieve adequate blood pressure control. The following are some key points to consider:

• More than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents, either initially as combination therapy or as add-on therapy if monotherapy and lifestyle modifications do not achieve adequate blood pressure control 4.
• Four main classes of medications are used in combination therapy for the treatment of hypertension: thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) 4.
• ACEIs and ARBs should not be used simultaneously 4.
• In black patients, at least one agent should be a thiazide diuretic or a calcium channel blocker 4.
• Patients with heart failure with reduced ejection fraction should be treated initially with a beta blocker and an ACEI or ARB (or an angiotensin receptor-neprilysin inhibitor), followed by add-on therapy with a mineralocorticoid receptor antagonist and a diuretic based on volume status 4.
• Treatment for patients with chronic kidney disease and proteinuria should include an ACEI or ARB plus a thiazide diuretic or a calcium channel blocker 4.
• Patients with diabetes mellitus should be treated similarly to those without diabetes unless proteinuria is present, in which case combination therapy should include an ACEI or ARB 4.

Choice of Antihypertensive Agent

The choice of antihypertensive agent depends on various factors, including the patient's demographics, comorbidities, and tolerance to medications. Some key points to consider are:

• Thiazide-type diuretics are superior in preventing one or more major forms of cardiovascular disease and are less expensive, and should be preferred for first-step antihypertensive therapy 5.
• Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have similar efficacy in reducing blood pressure and cardiovascular outcomes, but ARBs have fewer adverse events 6.
• Amlodipine, a calcium channel blocker, has a higher incidence of heart failure compared to chlorthalidone, a thiazide-type diuretic 5, 7.
• Lisinopril, an ACEI, has a higher incidence of coughing compared to losartan, an ARB, and amlodipine, a calcium channel blocker 8.

Monitoring and Follow-up

Regular monitoring and follow-up are essential to ensure that the patient's blood pressure is well-controlled and to adjust the treatment plan as needed. Some key points to consider are:

• Patients should be monitored regularly for changes in blood pressure, kidney function, and electrolyte levels 4.
• The treatment plan should be adjusted as needed to achieve adequate blood pressure control and to minimize adverse events 4.
• Patients should be educated on lifestyle modifications, such as diet and exercise, to help manage their hypertension 4.