What are the guidelines for managing hypertension, including lifestyle modifications and pharmacological interventions?

Guidelines for Managing Hypertension

For effective hypertension management, patients with confirmed blood pressure ≥130/80 mmHg should receive both lifestyle modifications and pharmacological therapy, with a target BP goal of <130/80 mmHg for most adults to reduce cardiovascular morbidity and mortality. 1, 2

Lifestyle Modifications

Lifestyle modifications are essential components of hypertension treatment and should be implemented for all patients with BP >120/80 mmHg, including:

Dietary Interventions

• DASH diet pattern: Rich in fruits, vegetables, whole grains, low-fat dairy products, and reduced in saturated fat and sodium 1
• Sodium restriction: Limit to <2,300 mg/day 1
• Potassium intake: Increase consumption of potassium-rich foods (avocados, nuts, legumes, leafy vegetables) 1
• Healthy beverages: Moderate consumption of coffee, green/black tea; consider beneficial drinks like hibiscus tea, pomegranate juice, and beetroot juice 1

Physical Activity

• At least 150 minutes of moderate-intensity aerobic activity per week 1
• Regular exercise has been shown to reduce blood pressure independently of weight loss 1

Weight Management

• Weight loss for overweight/obese individuals 1
• Target BMI 20-25 kg/m² or waist-to-height ratio <0.5 1

Alcohol Moderation

• Limit to ≤2 standard drinks/day for men and ≤1.5 standard drinks/day for women 1
• Avoid binge drinking 1

Additional Measures

• Smoking cessation 1
• Stress reduction and mindfulness practices 1
• Reduce exposure to air pollution and cold temperatures 1

Pharmacological Treatment

Initial Treatment Strategy

• BP 130-139/80-89 mmHg (Stage 1): Start with a single agent along with lifestyle modifications 2
• BP ≥140/90 mmHg (Stage 2): Initiate with two drugs from different classes plus lifestyle modifications 1, 2
• BP ≥160/100 mmHg: Prompt initiation and timely titration of two drugs 1

First-Line Medications

1. ACE inhibitors (e.g., lisinopril) 1, 2, 3
2. Angiotensin receptor blockers (ARBs) 1, 2
3. Calcium channel blockers (CCBs), preferably dihydropyridine type 1, 2
4. Thiazide or thiazide-like diuretics (e.g., chlorthalidone, indapamide) 1, 2, 4

Special Populations

Diabetes

• ACE inhibitors or ARBs are recommended first-line, especially with albuminuria 1, 2
• Target BP <130/80 mmHg 2

Chronic Kidney Disease

• ACE inhibitors or ARBs are first-line therapy, particularly with albuminuria 1, 2
• Consider loop diuretics if eGFR <30 ml/min/1.73m² 2
• Monitor renal function and electrolytes 2, 3

Heart Failure

• RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists are recommended 2
• Target BP <130/80 mmHg but >120/70 mmHg 2

Pregnancy and Women of Childbearing Potential

• Avoid ACE inhibitors and ARBs due to teratogenic potential 2
• For pregnant women with chronic hypertension, target BP 110-129/65-79 mmHg 2

Monitoring and Follow-up

• Follow-up within 2-4 weeks after starting or changing medications 2
• Monitor renal function and electrolytes 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or diuretics 2, 3
• Annual monitoring of renal function and electrolytes for patients on these medications 2
• Consider seasonal variation in BP (average 5/3 mmHg lower in summer) when adjusting medications 1

Important Cautions

• Avoid combining ACE inhibitors with ARBs - increases adverse effects without additional benefit 2, 3
• Beta-blockers are not recommended as first-line unless specifically indicated (e.g., coronary artery disease, heart failure) 2
• Monitor older patients with wide pulse pressures carefully when lowering SBP to avoid DBP <60 mmHg, which may increase risk of myocardial ischemia 2
• Adherence issues affect 10-80% of hypertensive patients and are a key driver of suboptimal BP control 1
• Fixed-dose combination therapy (multiple agents in a single pill) improves adherence and is recommended as initial therapy for many patients 2

By implementing these comprehensive guidelines for hypertension management, clinicians can effectively reduce cardiovascular morbidity and mortality in their patients.