What is the best approach to manage hypertension?

Management of Hypertension

The optimal approach to manage hypertension includes both lifestyle modifications and pharmacological therapy, with a target blood pressure of <140/90 mmHg for most patients and <130/80 mmHg for high-risk patients with diabetes, renal impairment, or established cardiovascular disease. 1, 2

Blood Pressure Assessment and Targets

Blood Pressure Measurement

• Measure BP following standardized techniques using properly calibrated devices
• Record at least two readings per visit
• Consider out-of-office measurements (home or ambulatory monitoring) to detect white coat or masked hypertension 1
• When using ambulatory readings, mean daytime pressures are approximately 10/5 mmHg lower than office readings 1

Blood Pressure Targets

• For most patients: ≤140/90 mmHg 1
• For high-risk patients (diabetes, renal impairment, established cardiovascular disease): ≤130/80 mmHg 1
• For adults ≥85 years: a more lenient target (<140/90 mmHg) may be appropriate 2

Lifestyle Modifications

Lifestyle modifications are the cornerstone of hypertension management and should be implemented for all patients:

1. Weight management 1, 2

   • Aim for BMI 20-25 kg/m²
   • Target waist circumference <94 cm in men and <80 cm in women
   • Each 1 kg of weight loss can reduce systolic BP by approximately 1 mmHg

2. Dietary approach 1, 2

   • Follow DASH diet (rich in fruits, vegetables, low-fat dairy)
   • Reduce sodium intake (<2,300 mg/day)
   • Increase potassium intake (3,500-5,000 mg/day)
   • Reduce saturated and total fat intake

3. Physical activity 1, 2

   • 150-300 minutes/week of moderate-intensity aerobic exercise
   • Include resistance training 2-3 sessions per week
   • Consider isometric exercises like hand-grip training

4. Alcohol moderation 1, 2

   • Men: ≤21 units per week with alcohol-free days
   • Women: ≤14 units per week with alcohol-free days

5. Smoking cessation 1, 2

   • Complete cessation is strongly recommended

6. Stress management 2

   • Consider cognitive behavioral techniques for stress reduction

Pharmacological Therapy

When to Initiate Drug Therapy

• Systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg despite lifestyle measures 1
• Systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg with target organ damage, established cardiovascular disease, diabetes, or 10-year cardiovascular risk ≥20% 1

First-Line Medications

The following classes have demonstrated cardiovascular event reduction in patients with hypertension:

1. Angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril) 1, 3
2. Angiotensin receptor blockers (ARBs) 1
3. Calcium channel blockers (CCBs) (e.g., amlodipine) 1, 4
4. Thiazide or thiazide-like diuretics 1

Special Considerations

• For patients with albuminuria (UACR ≥30 mg/g): ACE inhibitors or ARBs as first-line therapy 1
• For patients with established coronary artery disease: ACE inhibitors or ARBs as first-line therapy 1
• For resistant hypertension: consider adding spironolactone, eplerenone, or amiloride 2
• Avoid combinations of ACE inhibitors with ARBs 1

Monitoring and Follow-up

• Monthly follow-up until target BP is achieved 2
• Home BP monitoring to identify patterns and assess treatment effectiveness 1, 2
• Monitor for medication adherence, which affects 10-80% of hypertensive patients 2
• Check renal function and potassium within 1-2 weeks of initiating ACE inhibitors or ARBs 2
• BP-lowering treatment should be maintained lifelong if well tolerated 2

Common Pitfalls to Avoid

1. Inadequate BP measurement

   • Ensure proper technique, cuff size, and patient positioning
   • Consider white coat or masked hypertension with out-of-office measurements

2. Medication non-adherence

   • Simplify regimens when possible (once-daily dosing, combination pills)
   • Educate patients about the importance of consistent medication use

3. Overlooking secondary causes

   • Consider screening for primary aldosteronism in difficult-to-control or resistant hypertension 1

4. Ignoring drug interactions

   • Be cautious with NSAIDs, which can raise BP
   • Monitor potassium levels when using potassium supplements with ACE inhibitors/ARBs

5. Neglecting orthostatic hypotension

   • Measure standing BP in elderly patients
   • Note that asymptomatic orthostatic hypotension should not be a reason to withdraw treatment 1

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