How to manage hypertension?

Management of Hypertension

The cornerstone of hypertension management is a combination of lifestyle modifications and appropriate pharmacological therapy, with first-line drug treatment typically consisting of a thiazide-like diuretic, calcium channel blocker, or renin-angiotensin system blocker, often in combination therapy for most patients. 1

Diagnosis and Assessment

Before initiating treatment, proper assessment is essential:

• Measure BP accurately using standardized techniques
• Confirm hypertension with multiple readings on different occasions
• Consider out-of-office BP measurements (home or ambulatory monitoring) to detect white coat or masked hypertension 1
• Assess for target organ damage and cardiovascular risk factors
• Screen for secondary causes in appropriate patients (young age, resistant hypertension, sudden onset)

Blood Pressure Targets

Treatment goals should be based on patient characteristics:

• For most patients: target BP ≤140/85 mmHg 1
• For patients with diabetes, renal impairment, or established cardiovascular disease: target BP ≤130/80 mmHg 1
• For older adults (≥65 years): systolic BP <130 mmHg if tolerated 1

Lifestyle Modifications

All patients with hypertension should receive advice on the following lifestyle changes:

1. Healthy Diet: DASH diet (fruits, vegetables, whole grains, low-fat dairy, reduced saturated fat) can lower systolic BP by approximately 5 mmHg 1

2. Weight Management: Aim for ideal body weight; expect about 1 mmHg reduction in systolic BP for every 1 kg weight loss 1

3. Sodium Reduction: Optimal goal <1500 mg sodium/day; expect 1-3 mmHg reduction in systolic BP for every 1000 mg reduction in sodium intake 1

4. Increased Potassium Intake: Aim for 3500-5000 mg potassium/day through dietary sources 1

5. Physical Activity:

   • Aerobic exercise: 30-60 minutes, 5-7 times/week (at least 150 minutes/week)
   • Resistance training: 2-3 times/week as a supplement to aerobic exercise 1

6. Alcohol Moderation:

   • Men: ≤2 standard drinks/day (maximum 14/week)
   • Women: ≤1 standard drink/day (maximum 9/week) 1

Pharmacological Treatment

When to Initiate Drug Therapy

• Start drug treatment in all patients with sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg despite lifestyle modifications 1
• For patients with BP 140-159/90-99 mmHg, initiate drug therapy if target organ damage is present, cardiovascular disease exists, diabetes is present, or 10-year cardiovascular disease risk is ≥20% 1

First-Line Drug Therapy

The current evidence supports the following approach:

1. Initial Therapy Options:

   • Thiazide-like diuretic (preferably chlorthalidone or indapamide rather than hydrochlorothiazide) 1, 2
   • Calcium channel blocker (preferably long-acting amlodipine) 1
   • ACE inhibitor (e.g., lisinopril) 3
   • Angiotensin receptor blocker (e.g., losartan) 4

2. Combination Therapy:

   • Most patients will require multiple drugs to achieve BP targets
   • Consider starting with fixed-dose combinations for efficiency 1
   • Common effective combinations include:
     • ACE inhibitor or ARB + calcium channel blocker
     • ACE inhibitor or ARB + thiazide-like diuretic
     • Calcium channel blocker + thiazide-like diuretic

Special Population Considerations

• Black patients: First-line therapy should include a thiazide-like diuretic or calcium channel blocker; ARBs may be preferred over ACE inhibitors due to lower risk of angioedema 1
• Elderly patients: Start with lower doses and titrate gradually; monitor for orthostatic hypotension 1
• Diabetes: Target BP ≤130/80 mmHg; ACE inhibitors or ARBs are preferred first-line agents 1
• Chronic kidney disease: Target BP ≤130/80 mmHg; ACE inhibitors or ARBs are preferred 1

Monitoring and Follow-Up

• Schedule monthly visits until BP target is achieved 1
• Once controlled, provide 90-day rather than 30-day prescription refills when possible 1
• Use telehealth strategies to augment office-based management 1
• Encourage home BP monitoring to guide medication adjustments 1
• Assess medication adherence at each visit

Management of Resistant Hypertension

Resistant hypertension is defined as BP ≥130/80 mmHg despite ≥3 antihypertensive medications of different classes at maximum or maximally tolerated doses, or controlled BP requiring ≥4 medications 1.

For resistant hypertension:

• Confirm medication adherence
• Verify proper BP measurement technique
• Screen for secondary causes, particularly primary aldosteronism 1
• Consider adding a mineralocorticoid receptor antagonist
• Consider referral to a hypertension specialist

Team-Based Care

Implement multidisciplinary team-based care to enhance:

• Lifestyle adherence
• Medication adherence
• Management of social determinants of health 1

This comprehensive approach to hypertension management, combining lifestyle modifications with appropriate pharmacological therapy, is essential for reducing cardiovascular morbidity and mortality.