What are the treatment options for Hypertension (HTN)?

Treatment Options for Hypertension (HTN)

The treatment of hypertension should follow a stepwise approach beginning with lifestyle modifications for all patients, followed by pharmacological therapy based on blood pressure severity, with specific medication choices determined by patient characteristics and comorbidities. 1

Diagnosis and Assessment

Before initiating treatment, confirm hypertension diagnosis:

• Use validated automated upper arm cuff device with appropriate cuff size
• Measure BP in both arms at first visit; use arm with higher BP if consistent difference
• Confirm elevated office readings (≥130/85 mmHg) with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg)

Basic evaluation should include:

• Urine test for blood and protein
• Blood electrolytes and creatinine
• Blood glucose
• Lipid profile
• 12-lead ECG

Lifestyle Modifications

Lifestyle modifications are first-line treatment for all hypertensive patients and should include:

1. Diet modifications:

   • Salt reduction: Limit added salt and processed foods
   • DASH diet: Rich in whole grains, fruits, vegetables, and low-fat dairy
   • Increase potassium intake through foods like avocados, nuts, legumes
   • Moderate caffeine consumption

2. Physical activity:

   • Regular aerobic exercise (at least 150 minutes/week)
   • Dynamic activities like brisk walking preferred over isometric exercises

3. Weight management:

   • Achieve and maintain healthy body weight
   • Target BMI appropriate for ethnicity or waist-to-height ratio <0.5

4. Alcohol moderation:

   • Men: ≤2 standard drinks/day (maximum 14/week)
   • Women: ≤1.5 standard drinks/day (maximum 9/week)
   • Avoid binge drinking

5. Smoking cessation

6. Stress reduction and mindfulness practices

These lifestyle interventions can reduce systolic BP by 5-10 mmHg collectively and enhance the effectiveness of medication 1, 2.

Pharmacological Treatment

When to Initiate Drug Therapy:

• BP ≥160/100 mmHg (Grade 2 hypertension): Start drug treatment immediately along with lifestyle modifications
• BP 140-159/90-99 mmHg (Grade 1 hypertension):
  • Start drugs immediately in high-risk patients (CVD, CKD, diabetes, target organ damage, or age 50-80 years)
  • For low-risk patients: Try lifestyle modifications for 3-6 months first; if BP remains elevated, add medication 1

Medication Selection Algorithm:

For Non-Black Patients:

1. Start with low-dose ACE inhibitor (e.g., lisinopril) or ARB (e.g., losartan)
2. Increase to full dose if needed
3. Add thiazide/thiazide-like diuretic
4. Add calcium channel blocker (CCB)
5. If BP still uncontrolled, add spironolactone (or if contraindicated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker)

For Black Patients:

1. Start with low-dose ARB + dihydropyridine CCB or CCB + thiazide-like diuretic
2. Increase to full dose
3. Add diuretic or ACE inhibitor/ARB (whichever wasn't used initially)
4. If BP still uncontrolled, add spironolactone (or alternatives as above) 1

Special Populations:

Diabetes:

• Target BP <130/80 mmHg
• ACE inhibitors or ARBs preferred, especially with albuminuria
• Monitor kidney function and potassium when using ACE inhibitors, ARBs, or MRAs 1

Chronic Kidney Disease:

• ACE inhibitors or ARBs preferred first-line
• May continue these medications even as eGFR declines to <30 mL/min/1.73m² 1

Coronary Artery Disease:

• ACE inhibitors or ARBs recommended as first-line therapy 1

Pregnancy/Women of Childbearing Potential:

• ACE inhibitors, ARBs, MRAs, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy
• Avoid in sexually active women of childbearing potential not using reliable contraception 1

Monitoring and Follow-up

• Target BP: <130/80 mmHg for most adults
• For elderly patients, individualize targets based on frailty
• Aim to achieve target within 3 months
• Monitor for medication side effects:
  • Check serum creatinine and potassium 7-14 days after starting or changing doses of ACE inhibitors, ARBs, or MRAs
  • Monitor for hypokalemia with diuretics

Common Pitfalls to Avoid

1. Underestimating lifestyle modifications: These can be as effective as single-drug therapy in some patients and should be continued even when medications are needed 3

2. Ignoring seasonal BP variations: BP tends to be higher in cold weather and lower in warm weather (average 5/3 mmHg systolic/diastolic difference). Consider this when evaluating treatment effectiveness 1

3. Not accounting for racial differences in medication response: Black patients generally respond better to CCBs and diuretics than to ACE inhibitors or ARBs as monotherapy 4, 5

4. Inadequate medication adherence assessment: Poor adherence is a major cause of uncontrolled hypertension, affecting 10-80% of patients 1

5. Failing to use combination therapy when needed: Most patients with hypertension will require multiple medications to achieve target BP 6

By following this comprehensive approach to hypertension management, clinicians can significantly reduce patients' risk of cardiovascular events, stroke, and mortality.