What is the initial treatment approach for a patient with hypertension?

Initial Treatment Approach for Hypertension

The initial treatment approach for hypertension should include lifestyle modifications for all patients, with pharmacological therapy initiated immediately for those with stage 2 hypertension (≥160/100 mmHg) or high-risk patients with stage 1 hypertension (140-159/90-99 mmHg), while low-risk stage 1 patients may try lifestyle modifications for 3-6 months before starting medication. 1

Diagnosis and Assessment

Hypertension is defined as:

• Office BP ≥140/90 mmHg
• Home BP ≥135/85 mmHg
• 24-hour ambulatory BP ≥130/80 mmHg

Before initiating treatment, confirm the diagnosis with:

• Multiple BP readings (average of readings)
• Measurement in both arms (use arm with higher reading)
• Home or ambulatory BP monitoring to confirm office readings

Lifestyle Modifications (First-line for All Patients)

Implement the following lifestyle changes for all patients with BP >120/80 mmHg:

• Weight management: Achieve and maintain healthy body weight
• Dietary changes:
  • DASH-style eating pattern
  • Sodium restriction (<2,300 mg/day)
  • Increased potassium intake (fruits, vegetables)
  • Increased consumption of fruits (8-10 servings/day) and low-fat dairy products (2-3 servings/day)
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity weekly
• Alcohol moderation: ≤2 drinks/day for men (maximum 14/week), ≤1 drink/day for women (maximum 9/week)
• Smoking cessation

Pharmacological Therapy

When to Start Medications

1. Immediate drug therapy:

   • Stage 2 hypertension (≥160/100 mmHg)
   • High-risk patients with stage 1 hypertension (140-159/90-99 mmHg) who have:
     • Cardiovascular disease
     • Chronic kidney disease
     • Diabetes
     • Target organ damage
     • Age 50-80 years

2. Delayed drug therapy (after 3-6 months of lifestyle intervention):

   • Low-to-moderate risk patients with stage 1 hypertension with persistent BP elevation despite lifestyle changes

First-line Medication Selection

Non-Black Patients:

1. Low-dose ACE inhibitor (e.g., lisinopril 10 mg daily) 2 or ARB (e.g., losartan 50 mg daily) 3
2. If needed, increase to full dose
3. Add thiazide/thiazide-like diuretic
4. Add calcium channel blocker (CCB)

Black Patients:

1. Low-dose ARB (e.g., losartan) 3
2. Add dihydropyridine CCB or thiazide/thiazide-like diuretic
3. Increase to full dose
4. Add ACE inhibitor/ARB or diuretic (whichever wasn't added in step 2)

Special Considerations

• Diabetes: Initial treatment should include ACE inhibitor or ARB, especially with albuminuria 1
• Coronary artery disease: ACE inhibitor or ARB preferred as first-line therapy 1
• Elderly (>80 years) or frail patients: Consider monotherapy with simplified regimen 1
• Severe hypertension: Consider initiating with two-drug combination for BP ≥150/90 mmHg 1

Monitoring and Follow-up

• Target BP: <130/80 mmHg for most patients
• For elderly: Individualize targets based on frailty
• Monitor BP control and aim to achieve target within 3 months
• Monitor for medication side effects:
  • ACE inhibitors/ARBs: Monitor serum creatinine and potassium 7-14 days after initiation or dose change
  • Diuretics: Monitor for hypokalemia

Common Pitfalls to Avoid

1. Inadequate BP measurement: Always use validated devices with appropriate cuff size
2. Inappropriate drug combinations: Avoid combining ACE inhibitors with ARBs 1
3. Ignoring lifestyle modifications: Continue lifestyle interventions even after starting medications
4. Overlooking secondary causes: Consider screening for secondary hypertension in resistant cases
5. Medication non-adherence: Use once-daily dosing and single-pill combinations when possible to improve adherence

Remember that successful treatment of hypertension significantly reduces cardiovascular morbidity and mortality, with a 10 mmHg reduction in SBP decreasing CVD events by approximately 20-30% 4.