What is the recommended treatment for hypertension?

Recommended Treatment for Hypertension

The recommended treatment for hypertension begins with lifestyle modifications for all patients, followed by combination pharmacotherapy with a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) plus a calcium channel blocker (CCB) or thiazide-like diuretic for most patients with confirmed hypertension ≥140/90 mmHg, targeting a systolic blood pressure of 120-129 mmHg to reduce cardiovascular morbidity and mortality. 1

Initial Assessment and Diagnosis

• Confirm hypertension diagnosis using validated automated upper arm cuff device
• If office BP ≥130/85 mmHg, confirm with home BP monitoring (target <135/85 mmHg) or 24-hour ambulatory BP monitoring (target <130/80 mmHg) 1
• At first visit, measure BP in both arms; use arm with higher BP for subsequent measurements
• Consider additional tests if organ damage or secondary hypertension is suspected

Treatment Algorithm

Step 1: Lifestyle Modifications (for all patients)

• Weight reduction/maintenance (target BMI 20-25 kg/m²) 1
• Adopt DASH or Mediterranean diet 1
• Sodium restriction (<2,300 mg/day) 1
• Increase physical activity (150 minutes/week of moderate-intensity exercise) 1
• Limit alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) or avoid completely 1
• Smoking cessation 1

Step 2: Pharmacotherapy Initiation

• For BP ≥140/90 mmHg: Start combination therapy immediately 1
• For BP 130-139/80-89 mmHg with high CVD risk: Start pharmacotherapy after 3 months of lifestyle intervention 1
• For BP 130-139/80-89 mmHg with low/medium CVD risk: Continue lifestyle modifications 1

Step 3: Medication Selection Based on Patient Demographics

For Non-Black Patients:

1. Start with low-dose ACE inhibitor/ARB + dihydropyridine CCB or thiazide-like diuretic 1
2. Increase to full dose if needed
3. Add third agent (thiazide-like diuretic if not already included)
4. Add spironolactone for resistant hypertension 1, 2

For Black Patients:

1. Start with low-dose ARB + dihydropyridine CCB or thiazide-like diuretic 1
2. Increase to full dose if needed
3. Add diuretic or ACE inhibitor/ARB (whichever wasn't initially used)
4. Add spironolactone for resistant hypertension 1, 2

Special Populations

Patients with Diabetes

• Target BP <130/80 mmHg 1
• ACE inhibitor or ARB strongly recommended for those with albuminuria ≥300 mg/g creatinine 1

Patients with Chronic Kidney Disease

• Target systolic BP 120-129 mmHg for eGFR >30 mL/min/1.73m² 1
• RAS blockers recommended for those with albuminuria 1

Elderly Patients (≥60 years)

• Target systolic BP 120-129 mmHg if tolerated 1
• Consider monotherapy initiation in patients >80 years or frail 1
• Individualize BP targets based on frailty 1

Heart Failure Patients

• For HFrEF: ACE inhibitor/ARB, beta-blocker, diuretic, and/or mineralocorticoid receptor antagonist 1
• For HFpEF: Consider SGLT2 inhibitors 1

Management of Resistant Hypertension

Defined as BP ≥140/90 mmHg despite three antihypertensive drugs including a diuretic 1

1. Verify medication adherence
2. Add spironolactone 25 mg daily 1, 2
3. If spironolactone not tolerated, consider:
   • Eplerenone
   • Amiloride
   • Higher dose thiazide-like diuretic
   • Loop diuretic
   • Beta-blocker
   • Alpha-blocker (doxazosin)

Monitoring and Follow-up

• Target BP reduction of at least 20/10 mmHg 1
• Aim to achieve BP target within 3 months 1
• Monitor serum creatinine/eGFR and potassium annually for patients on ACE inhibitors, ARBs, or diuretics 1
• Use single-pill combinations when possible to improve adherence 1
• Take medications at the most convenient time of day to establish a habitual pattern 1

Common Pitfalls to Avoid

• Inadequate initial therapy: Most patients require combination therapy from the start 1
• Inappropriate drug combinations: Never combine two RAS blockers (ACE inhibitor + ARB) 1
• Insufficient monitoring: Failure to check electrolytes and renal function with certain medications
• Discontinuing treatment: BP-lowering medication should be maintained lifelong if tolerated 1
• Suboptimal lifestyle modifications: These enhance medication efficacy and should be continued even after starting pharmacotherapy 3, 4

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