What are the initial management guidelines for hypertension?

Initial Management Guidelines for Hypertension

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

Diagnostic Thresholds and Risk Assessment

• Hypertension is defined as persistent BP ≥140/90 mmHg
• Treatment decisions depend on:
  • BP level
  • Presence of target organ damage
  • Cardiovascular risk factors
  • Comorbidities

When to Initiate Drug Treatment:

• Immediate drug treatment for:
  • BP ≥160/100 mmHg despite lifestyle measures 1
  • BP ≥140/90 mmHg with target organ damage, established cardiovascular disease, diabetes, or 10-year cardiovascular disease risk ≥20% 1
  • BP ≥130/80 mmHg with high cardiovascular risk, after 3 months of lifestyle intervention 1

Lifestyle Modifications (First-Line for All Patients)

Lifestyle modifications should be recommended to all patients with elevated BP or hypertension:

1. Diet:

   • Mediterranean or DASH diet 1
   • Reduced sodium intake (avoid table salt and salty foods) 1
   • Increased fruit and vegetable consumption 1
   • Limit free sugar to <10% of energy intake 1
   • Avoid sugar-sweetened beverages 1

2. Physical Activity:

   • Regular dynamic exercise 1
   • Low to moderate-intensity resistance training 2-3 times/week 1

3. Weight Management:

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

4. Alcohol Moderation:

   • <100g/week of pure alcohol (preferably avoid completely) 1
   • <21 units/week for men and <14 units/week for women 1

5. Smoking Cessation:

   • Complete cessation with supportive care 1

Pharmacological Treatment

First-Line Drug Therapy:

For most patients with confirmed hypertension (BP ≥140/90 mmHg):

• Start with combination therapy using fixed-dose single-pill combinations 1
• Preferred initial combinations:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB or thiazide-like diuretic 1
  • Example: Lisinopril (starting 10mg daily) 2 + Amlodipine or Chlorthalidone (starting 25mg daily) 3

Special Considerations:

• Monotherapy may be considered for:
  • Patients aged ≥85 years
  • Those with symptomatic orthostatic hypotension
  • Moderate-to-severe frailty 1

Treatment Escalation:

• If BP not controlled with a two-drug combination, increase to a three-drug combination:
  • RAS blocker + dihydropyridine CCB + thiazide-like diuretic 1
  • Preferably as a single-pill combination 1

BP Targets

• For most adults: Target systolic BP 120-129 mmHg 1
• For patients with diabetes, renal impairment, or established cardiovascular disease: Target BP ≤130/80 mmHg 1
• Minimum acceptable control (audit standard): <150/90 mmHg 1

Follow-Up and Monitoring

1. Monthly visits until BP target is achieved 1
2. Home BP monitoring to guide medication titration 1
3. Consider 90-day refills instead of 30-day to improve adherence 1
4. Team-based care approach to enhance lifestyle and medication adherence 1

Common Pitfalls to Avoid

1. Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1
2. Delaying treatment in high-risk patients can lead to earlier onset of cardiovascular events 1
3. Inadequate attention to lifestyle modifications - these are complementary to drug therapy and can reduce medication requirements 1
4. Failure to screen for secondary causes in resistant hypertension or young patients 1
5. Not accounting for white coat hypertension - consider ambulatory or home BP monitoring when clinic readings show unusual variability 1

By following these guidelines, clinicians can effectively manage hypertension and reduce the risk of cardiovascular morbidity and mortality in their patients.