What is the algorithm for managing chronic elevated blood pressure (hypertension)?

From the Guidelines

The management of chronic elevated blood pressure (hypertension) begins with lifestyle modifications for all patients, including weight reduction, adopting the DASH diet, reducing sodium intake to less than 2.3g daily, regular physical activity, and limiting alcohol consumption, as recommended by the most recent guidelines 1.

Lifestyle Modifications

• Weight reduction: maintain a normal body mass index (BMI) of 18.5-24.9 kg/m2, with an approximate systolic blood pressure (SBP) reduction of 5-20 mm Hg/10 kg 1
• Adopt DASH eating plan: consume a diet rich in fruits, vegetables, and low-fat dairy products, with an approximate SBP reduction of 8-14 mm Hg 1
• Dietary sodium reduction: reduce sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride), with an approximate SBP reduction of 2-8 mm Hg 1
• Physical activity: engage in regular aerobic physical activity, such as brisk walking, for at least 30 minutes per day, most days of the week, with an approximate SBP reduction of 4-9 mm Hg 1
• Moderation of alcohol consumption: limit consumption to no more than 2 drinks per day in most men and no more than 1 drink per day in women and lighter-weight persons, with an approximate SBP reduction of 2-4 mm Hg 1

Pharmacotherapy

If blood pressure remains ≥140/90 mmHg despite lifestyle modifications, pharmacotherapy is indicated.

• First-line medications: thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs, with treatment typically starting with a single agent at a low dose, titrating upward if needed 1
• Special populations: ACE inhibitors or ARBs are preferred for patients with diabetes or chronic kidney disease, while beta-blockers are beneficial for those with coronary artery disease 1
• Regular monitoring: essential, with a goal of <130/80 mmHg for most adults, and <110/75 mmHg for individuals with chronic kidney disease, as recommended by the most recent guidelines 1

Algorithm for Managing Chronic Elevated Blood Pressure

1. Lifestyle modifications: implement lifestyle changes for all patients, as outlined above
2. Pharmacotherapy: initiate pharmacotherapy if blood pressure remains ≥140/90 mmHg despite lifestyle modifications
3. First-line medications: choose a first-line medication, such as a thiazide diuretic, calcium channel blocker, ACE inhibitor, or ARB
4. Titration and combination therapy: titrate the dose upward if needed, and add a second medication from a different class if blood pressure remains uncontrolled on a maximum dose
5. Regular monitoring: monitor blood pressure regularly, with a goal of <130/80 mmHg for most adults, and <110/75 mmHg for individuals with chronic kidney disease, as recommended by the most recent guidelines 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)

The algorithm for managing chronic elevated blood pressure (hypertension) involves:

• Comprehensive cardiovascular risk management
• Lifestyle modifications:
  • Lipid control
  • Diabetes management
  • Antithrombotic therapy
  • Smoking cessation
  • Exercise
  • Limited sodium intake
• Pharmacological therapy: Many patients will require more than one drug to achieve blood pressure goals
• Guideline-directed management: 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

From the Research

Algorithm for Managing Chronic Elevated Blood Pressure

The management of chronic elevated blood pressure, also known as hypertension, involves a combination of lifestyle modifications and pharmacological interventions. The following steps outline the algorithm for managing hypertension:

• Lifestyle Modifications:
  • Dietary changes: Adopting a diet rich in plant-based foods, whole grains, low-fat dairy products, and reducing sodium intake to within normal limits 4
  • Regular exercise: Increasing physical activity has extensive benefits, including improving both blood pressure and blood cholesterol 5
  • Weight loss: Moderate weight loss is associated with improvements in blood pressure 6
  • Moderation of alcohol consumption: Reducing alcohol intake is recommended for patients with elevated blood pressure 7
• Pharmacological Interventions:
  • First-line antihypertensive medications: Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics are recommended as first-line treatments 8, 6, 7
  • Combination therapy: More than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents 8
  • Special considerations:
    • Black patients: Thiazide diuretics or calcium channel blockers are preferred 8, 6
    • Patients with heart failure: Beta blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are recommended 8
    • Patients with chronic kidney disease: Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers plus a thiazide diuretic or a calcium channel blocker are recommended 8, 6
    • Patients with diabetes mellitus: Treatment should include an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, unless proteinuria is present, in which case combination therapy should include an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker 8, 6
• Blood Pressure Goals:
  • Less than 140/90 mm Hg is recommended for most adults 6, 7
  • Less than 135/85 mm Hg may further reduce the risk of myocardial infarction 7
  • Clinical judgment and shared decision-making should guide treatment of patients with mild hypertension and older adults 7