What are the recommended treatments for managing hypertension?

Recommended Treatments for Managing Hypertension

The management of hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy with combination treatment using a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1

Lifestyle Modifications

Lifestyle modifications are essential for all patients with elevated blood pressure or hypertension:

1. Diet:

   • Follow DASH diet (rich in whole grains, fruits, vegetables, polyunsaturated fats, and dairy products) 1, 2
   • Reduce sodium intake (avoid added salt and high-sodium processed foods) 1
   • Increase potassium intake through foods like avocados, nuts, seeds, legumes, and tofu 1
   • Limit sugar consumption, especially sugar-sweetened beverages 1

2. Physical Activity:

   • Regular aerobic exercise (walking, jogging, cycling, swimming) for 30 minutes on 5-7 days per week 1
   • Strength/resistance training 2-3 days per week 1
   • High-intensity interval training (HIIT) can be beneficial 1

3. Weight Management:

   • Achieve and maintain healthy BMI (20-25 kg/m²) 1
   • Target waist circumference <94 cm for men and <80 cm for women 1

4. Alcohol Consumption:

   • Limit to ≤2 standard drinks per day for men and ≤1.5 for women 1
   • Preferably avoid alcohol completely for best health outcomes 1

5. Smoking Cessation:

   • Complete cessation with referral to smoking cessation programs 1

6. Stress Management:

   • Consider mindfulness, meditation, or stress reduction techniques 1

Pharmacological Treatment

When to Initiate Drug Therapy:

• Immediate treatment for patients with BP ≥140/90 mmHg 1
• For BP 130-139/80-89 mmHg with high cardiovascular risk or target organ damage 1
• For BP 120-129/70-79 mmHg, consider lifestyle modifications first for 3-6 months 1

First-Line Drug Therapy:

• Combination therapy is recommended for most patients with confirmed hypertension (≥140/90 mmHg) 1
• Preferred initial combinations:
  1. RAS blocker (ACE inhibitor like lisinopril 3 or ARB) + dihydropyridine CCB (like amlodipine 4)
  2. RAS blocker + thiazide/thiazide-like diuretic 1
• Single-pill fixed-dose combinations are preferred to improve adherence 1

Step-wise Treatment Approach:

1. Step 1: Two-drug combination (RAS blocker + CCB or diuretic)
2. Step 2: If BP not controlled, increase to three-drug combination (RAS blocker + CCB + thiazide/thiazide-like diuretic)
3. Step 3: If BP still not controlled, consider adding spironolactone 1
4. Step 4: Consider adding beta-blockers, alpha-blockers, or other agents if needed 1

BP Targets:

• Target systolic BP 120-129 mmHg for most adults if well tolerated 1
• For patients ≥65 years, consider individual targets based on frailty and tolerability 1
• If target cannot be achieved, aim for "as low as reasonably achievable" (ALARA principle) 1

Special Considerations

1. Comorbidities:

   • Coronary Artery Disease: RAS blockers and beta-blockers are first-line 1
   • Previous Stroke: RAS blockers, CCBs, and diuretics are first-line 1
   • Heart Failure: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1
   • Chronic Kidney Disease: RAS blockers are preferred 1

2. Medication Adherence:

   • Take medications at the most convenient time of day to establish a routine 1
   • Consider fixed-dose combinations to reduce pill burden 1

3. Common Pitfalls to Avoid:

   • Never combine two RAS blockers (ACE inhibitor and ARB) due to increased adverse effects 1
   • Don't underestimate the importance of lifestyle modifications even when on medications 1
   • Don't delay treatment in high-risk patients or those with BP ≥140/90 mmHg 1
   • Avoid abrupt discontinuation of beta-blockers
   • Monitor for orthostatic hypotension, especially in elderly patients 1

4. Additional Cardiovascular Risk Reduction:

   • Consider aspirin for secondary prevention or primary prevention in high-risk patients with controlled BP 1
   • Consider statins for patients with elevated cardiovascular risk 1

By following this comprehensive approach to hypertension management, focusing on both lifestyle modifications and appropriate pharmacological therapy, the risk of cardiovascular morbidity and mortality can be significantly reduced.