What are the initial management steps for hypertension?

Initial Management Steps for Hypertension

The cornerstone of initial hypertension management is lifestyle modification for all patients, followed by pharmacological therapy with first-line agents including ACE inhibitors/ARBs, calcium channel blockers, or thiazide-like diuretics for those with sustained blood pressure ≥140/90 mmHg or high cardiovascular risk. 1, 2

Diagnosis and Blood Pressure Assessment

• Use validated automated upper arm cuff device with appropriate cuff size
• Measure BP after 5 minutes of rest, with patient seated comfortably with back supported and feet on floor
• Take at least 2 readings and average them
• Consider home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) to exclude white-coat hypertension
• Normal BP: <130/85 mmHg
• Elevated BP: 130-139/85-89 mmHg
• Grade 1 hypertension: 140-159/90-99 mmHg
• Grade 2 hypertension: ≥160/100 mmHg 2, 1

Lifestyle Modifications

Implement these for all patients with elevated BP or hypertension:

• Dietary modifications:

  • DASH diet (rich in fruits, vegetables, legumes, low-fat dairy; low in saturated fat)
  • Sodium restriction (<2,300 mg/day)
  • Increased potassium intake
  • Moderate alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) 1, 3, 4

• Physical activity:

  • At least 30 minutes of moderate-intensity aerobic exercise 5-7 days/week (can reduce BP by 4-9 mmHg) 1

• Weight management:

  • Target BMI <25 kg/m² (weight loss can reduce BP by 5-20 mmHg in overweight/obese patients) 1

• Smoking cessation 1

Pharmacological Therapy

When to Initiate Drug Treatment

• Immediate initiation for:

  • Grade 2 hypertension (≥160/100 mmHg)
  • Grade 1 hypertension (140-159/90-99 mmHg) with high cardiovascular risk, target organ damage, diabetes, or CKD
  • Patients aged 50-80 years with Grade 1 hypertension 2

• After 3-6 months of lifestyle intervention for:

  • Grade 1 hypertension with low-moderate cardiovascular risk and persistent BP elevation 2

First-Line Medication Options

1. Non-Black Patients:

   • Start with low-dose ACE inhibitor/ARB (e.g., enalapril)
   • Alternative: Dihydropyridine calcium channel blocker (e.g., amlodipine) or thiazide-like diuretic (e.g., chlorthalidone) 2, 1

2. Black Patients:

   • Start with low-dose ARB + dihydropyridine calcium channel blocker or
   • Dihydropyridine calcium channel blocker + thiazide-like diuretic 2

3. Special Considerations:

   • For patients with albuminuria: Prefer ACE inhibitors or ARBs
   • For patients with established coronary disease or CKD: Prefer ACE inhibitors or ARBs 1
   • For elderly or frail patients: Consider monotherapy with more gradual titration 1, 5

Medication Dosing and Titration

• Chlorthalidone: Start with 25 mg once daily in the morning with food; may increase to 50 mg if insufficient response 5
• Enalapril: Start with low dose and titrate up; monitor for hypotension, especially in patients on diuretics, with heart failure, or salt/volume depletion 6
• Allow at least 4 weeks to observe full response before dose adjustment 2
• Target: Reduce BP by at least 20/10 mmHg; ideally to <140/90 mmHg for most adults 2
• For patients with diabetes, CKD, or established cardiovascular disease: Target <130/80 mmHg 2, 1

Follow-Up and Monitoring

• Reassess within 2-4 weeks to evaluate BP control, medication adherence, and response to treatment 1
• Monthly visits until BP target is achieved 2
• Check serum creatinine and potassium 7-14 days after initiation or dose change of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Consider 90-day prescription refills instead of 30-day when BP is controlled 2
• Use telehealth strategies to augment office-based management 2

Management of Resistant Hypertension

If BP remains uncontrolled on three medications at optimal doses (including a diuretic):

1. Confirm medication adherence
2. Exclude white-coat hypertension using ABPM
3. Consider adding spironolactone or, if not tolerated, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 2, 1

Common Pitfalls to Avoid

• Inadequate BP measurement: Always use proper technique and validated devices
• Therapeutic inertia: Don't delay treatment intensification when targets aren't met
• Ignoring white-coat or masked hypertension: Consider ABPM or HBPM for diagnosis
• Medication combinations to avoid: Never combine two RAS blockers (ACE inhibitor + ARB)
• Overlooking adherence issues: Use single-pill combinations when possible to improve adherence
• Avoiding beta-blocker + thiazide diuretic combination in patients with metabolic syndrome due to dysmetabolic effects 1

By following these evidence-based steps for hypertension management, you can significantly reduce cardiovascular morbidity and mortality in your patients.