What are the treatment options for Hypertension (HTN)?

Treatment Options for Hypertension

The management of hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy with ACE inhibitors/ARBs, calcium channel blockers, or thiazide diuretics as first-line agents, with treatment regimens tailored based on patient demographics and comorbidities. 1, 2

Diagnosis and Classification

Hypertension is diagnosed when blood pressure is persistently:

• Grade 1: 140-159/90-99 mmHg
• Grade 2: ≥160/100 mmHg

Diagnosis should be confirmed with:

• Office BP measurements (average of at least 2 readings)
• Home BP monitoring (≥135/85 mmHg indicates hypertension)
• 24-hour ambulatory BP monitoring (≥130/80 mmHg indicates hypertension)

Treatment Algorithm

Step 1: Lifestyle Modifications (for all patients)

• Dietary changes:

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

• Physical activity:

  • At least 30 minutes of moderate-intensity aerobic exercise 5-7 days/week 2

• Weight management:

  • Target BMI <25 kg/m² 2

• Smoking cessation 2

Step 2: Pharmacological Therapy

When to initiate medications:

• Immediately for Grade 2 hypertension (≥160/100 mmHg)
• Immediately for Grade 1 hypertension with high CV risk, target organ damage, diabetes, CKD, or age 50-80 years
• After 3-6 months of lifestyle modifications for others with persistent Grade 1 hypertension 1

First-line medications:

1. ACE inhibitors (e.g., lisinopril) or ARBs (e.g., losartan)
2. Calcium channel blockers (CCBs)
3. Thiazide or thiazide-like diuretics 1, 2

Population-specific initial therapy:

• For non-Black patients:

  • Start with low-dose ACE inhibitor/ARB
  • If inadequate response, increase to full dose
  • Add thiazide/thiazide-like diuretic
  • Add spironolactone, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker if needed 1

• For Black patients:

  • Start with low-dose ARB + CCB or CCB + thiazide/thiazide-like diuretic
  • If inadequate response, increase to full dose
  • Add diuretic or ACE/ARB if not already included
  • Add spironolactone, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker if needed 1

Step 3: Treatment Monitoring and Adjustment

• Target BP: Reduce by at least 20/10 mmHg; ideally to <140/90 mmHg for most adults 1
• More aggressive targets (<130/80 mmHg) for patients with diabetes, CKD, or established cardiovascular disease 2
• Monitor BP control within 2-4 weeks after treatment initiation or adjustment 2
• Check serum creatinine and potassium 7-14 days after initiation or dose change of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2

Special Considerations

Resistant Hypertension

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

1. Add spironolactone
2. If spironolactone is not tolerated, consider eplerenone, amiloride, higher-dose thiazide diuretic, beta-blocker, alpha-blocker, or centrally acting agent 1

Comorbidities

• Chronic Kidney Disease:

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

• Heart Failure:

  • For HFrEF: ACE inhibitor/ARB, beta-blocker, diuretic, MRA, and SGLT2 inhibitor
  • For HFpEF: SGLT2 inhibitors recommended; ARBs/MRAs may be considered 1

• Stroke:

  • Target systolic BP: 120-130 mmHg 1

• Elderly patients:

  • Consider monotherapy with more gradual titration
  • Target systolic BP <150 mmHg for most adults aged ≥65 years 2

Medication Benefits and Considerations

• ACE inhibitors/ARBs:

  • Indicated for hypertension in adults and children ≥6 years
  • Reduce CV events, primarily strokes and myocardial infarctions
  • ARBs (e.g., losartan) have lower incidence of cough compared to ACE inhibitors 3, 4
  • Contraindicated in pregnancy 2

• Combination therapy:

  • Single-pill combinations improve adherence
  • Never combine two RAS blockers (ACE inhibitor + ARB) 2

Common Pitfalls to Avoid

1. Inadequate lifestyle modifications: Lifestyle changes alone can reduce BP by 4-9 mmHg and enhance effects of medications 5, 6

2. Insufficient monitoring: Allow at least 4 weeks to observe full response to treatment before adjusting dose 2

3. White coat hypertension: Confirm office readings with home or ambulatory BP monitoring 2

4. Medication non-adherence: Consider once-daily dosing and single-pill combinations to improve compliance 1

5. Ignoring secondary causes: Consider secondary hypertension in resistant cases 2

6. Inappropriate combinations: Avoid dual RAS blockade (ACE inhibitor + ARB) 2

7. Overlooking sodium intake: Dietary sodium restriction is a cornerstone of non-pharmacological management 7, 8, 9