What are the recommended management strategies for hypertension?

Hypertension Management Strategies

The management of hypertension should follow a stepped approach starting with lifestyle modifications for all patients, followed by pharmacological therapy with ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics as first-line medications, targeting blood pressure below 140/90 mmHg for most patients and 130/80 mmHg for high-risk individuals. 1

Lifestyle Modifications (First-line for all patients)

Lifestyle modifications are recommended for all patients with hypertension and should include:

• Regular physical activity: 30 minutes of moderate dynamic aerobic exercise on 5-7 days per week, complemented with resistance training 2-3 times weekly 1
• Weight management: Target BMI of 20-25 kg/m² and waist circumference <94 cm in men and <80 cm in women 1
• Dietary modifications:
  • Salt restriction to 5-6 g per day 1
  • Increased consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids (olive oil) 1
  • Low consumption of red meat and low-fat dairy products 1
• Alcohol limitation:
  • Men: <14 units/week
  • Women: <8 units/week 1
• Smoking cessation for all patients 1

These lifestyle interventions can produce significant blood pressure reductions:

• Weight loss: approximately 1 mmHg reduction per kg lost
• Salt restriction: 3-5 mmHg reduction
• Physical activity: 3-5 mmHg reduction
• Alcohol moderation: 3-4 mmHg reduction

Pharmacological Therapy

When blood pressure remains elevated despite lifestyle modifications, or in patients with high cardiovascular risk, drug therapy should be initiated:

First-line Medications

The following drug classes have demonstrated effective BP reduction and CV event reduction 1:

• ACE inhibitors (e.g., lisinopril) 2
• Angiotensin receptor blockers (ARBs)
• Calcium channel blockers (e.g., amlodipine) 3
• Thiazide and thiazide-like diuretics (chlorthalidone, indapamide)
• Beta-blockers (in specific situations)

Treatment Algorithm

1. Initial therapy:

   • For mild hypertension with low/moderate CV risk: Monotherapy
   • For BP ≥160/100 mmHg or high CV risk: Initial combination therapy with two drugs at low doses 4

2. If BP not at target:

   • Increase to full-dose monotherapy or add a second agent from a different class

3. If still not controlled:

   • Triple therapy: Usually combining an ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic

4. Resistant hypertension:

   • Add spironolactone or, if not tolerated, eplerenone
   • Consider beta-blockers, alpha-blockers, or centrally acting agents 1

Recommended Combination Therapies

• ACE inhibitor + calcium channel blocker
• ACE inhibitor + thiazide diuretic
• ARB + calcium channel blocker
• ARB + thiazide diuretic
• Calcium channel blocker + thiazide diuretic 4

Blood Pressure Targets

• General population: <140/90 mmHg initially, then target 120-129/<80 mmHg if tolerated 1
• High-risk patients (diabetes, renal dysfunction, established cardiovascular disease): <130/80 mmHg 1
• Older patients (≥65 years): Target systolic BP of 130-139 mmHg 1
• Very elderly (≥85 years): Consider more lenient targets (<140/90 mmHg) 1

Monitoring and Follow-up

• Regular follow-up appointments until target BP is achieved (typically monthly) 4
• Home BP monitoring to detect white coat hypertension and monitor treatment effectiveness 4
• Ambulatory BP monitoring when clinic readings show unusual variability or suspected white coat hypertension 1
• Monitor for medication side effects and adherence
• For patients on ACE inhibitors or ARBs, check renal function and potassium within 1-2 weeks of initiation 4

Special Considerations

Hypertensive Urgency/Emergency

• Hypertensive emergency (BP >180/120 mmHg with end-organ damage): Requires immediate hospitalization and IV medications 5
• Hypertensive urgency (severe hypertension without acute end-organ damage): Can be treated with oral medications in outpatient setting 5

Drug Interactions

• NSAIDs can reduce the effectiveness of antihypertensive medications 4
• Monitor potassium levels when using potassium-sparing diuretics, ACE inhibitors, or ARBs 4

Secondary Hypertension

Consider evaluation for secondary causes when:

• Sudden onset or worsening of hypertension
• Resistant to multidrug regimen (≥3 drugs)
• Young age (<30 years needing treatment)
• Presence of clinical clues (hypokalemia, elevated creatinine) 1

Common Pitfalls to Avoid

1. Inadequate BP measurement: Ensure proper technique with validated devices and appropriate cuff size
2. Medication non-adherence: Simplify regimens when possible (once-daily dosing, fixed-dose combinations) 1
3. Ignoring white coat or masked hypertension: Use home or ambulatory monitoring when suspected
4. Overlooking secondary causes: Screen appropriately in resistant hypertension
5. Neglecting orthostatic hypotension: Check standing BP in elderly patients
6. Insufficient lifestyle counseling: Provide specific, actionable advice and regular reinforcement

By following these evidence-based strategies for hypertension management, clinicians can effectively reduce blood pressure and minimize the risk of cardiovascular events, stroke, and mortality in patients with hypertension.