What is the treatment regimen for hypertension?

Treatment Regimen for Hypertension

The first-line treatment for hypertension should include a combination of ACE inhibitors/ARBs, dihydropyridine calcium channel blockers, and thiazide/thiazide-like diuretics, preferably as a low-dose combination therapy for most patients with confirmed hypertension. 1

Initial Treatment Approach

Blood Pressure Classification and Initial Therapy

• For BP 140-159/90-99 mmHg: Start with a single-pill combination of two first-line agents at low doses
• For BP ≥160/100 mmHg: Immediate initiation of two-drug combination therapy is strongly recommended 1
• For elevated BP (not yet hypertensive): Monotherapy may be considered 1

First-Line Medication Options

1. Renin-Angiotensin System (RAS) Blockers:

   • ACE inhibitors (e.g., enalapril, lisinopril)
   • ARBs (e.g., candesartan, valsartan) - use when ACE inhibitors cause cough or angioedema

2. Calcium Channel Blockers (CCBs):

   • Dihydropyridine CCBs (e.g., amlodipine, nifedipine) 2

3. Diuretics:

   • Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)

4. Beta-Blockers (e.g., atenolol 3):

   • Not recommended as first-line unless specifically indicated (e.g., coronary artery disease, heart failure) 1

Treatment Escalation Algorithm

1. Step 1: Start with a two-drug combination (RAS blocker + CCB or RAS blocker + thiazide diuretic)

2. Step 2: If BP remains uncontrolled, optimize the initial two-drug combination to maximum tolerated doses

3. Step 3: Progress to a three-drug combination: RAS blocker + CCB + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1

4. Step 4: For resistant hypertension (uncontrolled on triple therapy), add spironolactone as a fourth-line agent. Alternative options include eplerenone, beta-blocker, centrally acting agent, or alpha-blocker 1

Special Population Considerations

Patients with Diabetes or Kidney Disease

• ACE inhibitors or ARBs should be the first-line therapy for patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g) 1
• Immediate drug treatment is recommended for patients with diabetes or evidence of organ damage 1

Patients with Coronary Artery Disease

• Beta-blockers like atenolol 3 and ACE inhibitors are recommended for patients with a history of prior MI 4
• If beta-blockers are contraindicated, a non-dihydropyridine CCB (diltiazem or verapamil) can be substituted, but not if there is LV dysfunction 4

Pregnant Women

• ACE inhibitors and ARBs should be avoided due to teratogenic potential 1
• For pregnant women with chronic hypertension, BP targets of 110-129/65-79 mmHg are suggested 4

Hypertensive Crisis Management

Hypertensive Emergency (with acute organ damage)

• Requires immediate BP reduction with intravenous medications in an intensive care setting 4, 5
• IV options include labetalol, esmolol, fenoldopam, nicardipine, sodium nitroprusside, and clevidipine 5
• Avoid hydralazine, immediate-release nifedipine, and nitroglycerin 5

Hypertensive Urgency (severe hypertension without acute organ damage)

• Can be treated with oral medications on an outpatient basis 4, 5
• Follow standard drug treatment algorithm with closer follow-up 4

Lifestyle Modifications

Implement these concurrently with pharmacotherapy:

• Weight reduction for overweight individuals (target BMI 20-25 kg/m²)
• DASH dietary pattern (rich in fruits, vegetables, and low-fat dairy products)
• Sodium restriction to <5 g/day
• Regular physical activity (30 minutes on at least 3 days per week) 6
• Moderation of alcohol consumption (≤20 g/day for men, ≤10 g/day for women)
• Smoking cessation 1

Blood Pressure Targets

• General target: <130/80 mmHg for most adults 1
• Optimal target: Systolic BP 120-129 mmHg if tolerated 1
• For patients with CAD and HF: Target BP <130/80 mmHg, with consideration for even lower targets (<120/80 mmHg) if tolerated 4
• For older hypertensive individuals with wide pulse pressures: Monitor carefully when lowering SBP to avoid DBP <60 mmHg, which may increase risk of myocardial ischemia 4

Monitoring and Follow-up

• Follow-up within 2-4 weeks after starting or changing medications 1
• Check serum creatinine and potassium 7-14 days after initiation or dose change of ACE inhibitors/ARBs or diuretics 1
• Annual monitoring of renal function and electrolytes for patients on ACE inhibitors, ARBs, or diuretics 1
• Take at least two BP measurements at each visit with the patient seated and arm at heart level 1

Common Pitfalls to Avoid

1. Inappropriate combinations: Do not combine ACE inhibitors with ARBs or direct renin inhibitors, as this increases adverse effects without additional benefit 1

2. Rapid BP reduction: In hypertensive emergencies, avoid rapid and uncontrolled BP lowering as this can lead to further complications 4

3. Inadequate follow-up: Failure to monitor renal function and electrolytes when using ACE inhibitors, ARBs, or diuretics can lead to complications 1

4. Monotherapy for severe hypertension: Starting with a single agent for BP ≥160/100 mmHg is less effective than combination therapy 1, 7

5. Ignoring lifestyle modifications: Relying solely on medications without addressing lifestyle factors reduces overall treatment effectiveness 1, 6