What are the current recommendations for managing Hypertension (HTN)?

Current Recommendations for Managing Hypertension (HTN)

The current recommendations for managing hypertension include lifestyle modifications as first-line therapy, followed by pharmacological treatment with a target blood pressure of <130/80 mmHg for most patients, using combinations of thiazide-like diuretics, ACE inhibitors/ARBs, and calcium channel blockers as first-line medications. 1, 2

Diagnosis and Classification

• Hypertension is defined as persistent systolic blood pressure (SBP) ≥130 mmHg or diastolic BP (DBP) ≥80 mmHg 3
• Proper measurement technique is essential:
  • Patient seated with arm at heart level
  • Properly calibrated device with appropriate cuff size
  • At least two measurements at each visit
  • Standing measurements for elderly and diabetic patients 2

Lifestyle Modifications

Lifestyle modifications are the foundation of hypertension management and should be recommended to all patients:

1. Dietary Approaches:

   • DASH diet (rich in fruits, vegetables, low-fat dairy products) reduces SBP by 3-5 mmHg 2, 4
   • Sodium restriction to <2,300 mg/day reduces SBP by 3-5 mmHg 2, 5
   • Increase potassium intake to 3,500-5,000 mg/day 2

2. Physical Activity:

   • Regular dynamic aerobic exercise reduces resting BP by 3.0/2.4 mmHg 2
   • Aim for at least 150 minutes of moderate-intensity activity per week

3. Weight Management:

   • Target BMI of 20-25 kg/m² and waist circumference <94 cm in men, <80 cm in women
   • Each 1 kg of weight loss reduces systolic BP by approximately 1 mmHg 2

4. Alcohol Moderation:

   • Limit to <21 units/week with alcohol-free days 2
   • Can reduce SBP by 3-4 mmHg

5. Smoking Cessation:

   • Essential for overall cardiovascular risk reduction 2

Pharmacological Treatment

When to Initiate Drug Therapy

• If seated office BP >140/90 mmHg despite lifestyle modifications 1
• Consider earlier initiation in high-risk patients (diabetes, established cardiovascular disease, chronic kidney disease) 2

First-Line Medications

1. Thiazide and thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide)
2. ACE inhibitors (e.g., enalapril, lisinopril)
3. Angiotensin receptor blockers (ARBs) (e.g., candesartan, valsartan)
4. Calcium channel blockers (CCBs) (e.g., amlodipine) 2, 3

Treatment Strategy

• Initial monotherapy is appropriate for mild hypertension with low/moderate cardiovascular risk 2

• Initial combination therapy (two drugs at low doses) is recommended for:

  • Grade 2-3 hypertension (BP ≥160/100 mmHg)
  • High or very high cardiovascular risk patients 2

• Recommended combinations:

  • Thiazide diuretic + ACE inhibitor/ARB
  • Calcium antagonist + ACE inhibitor/ARB
  • Calcium antagonist + thiazide diuretic 2

Special Populations

1. Resistant Hypertension:

   • Add spironolactone as 4th line agent if serum potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m² 1
   • Alternative options: amiloride, doxazosin, eplerenone, clonidine, beta-blockers 1
   • Refer to specialist centers for management 1

2. Patients with Comorbidities:

   • Coronary Artery Disease: RAS blockers, beta-blockers with or without CCBs 1
   • Previous Stroke: RAS blockers, CCBs, and diuretics 1
   • Heart Failure: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1
   • Chronic Kidney Disease: ACE inhibitors or ARBs as first-line therapy 2

3. Pregnancy:

   • Preexisting hypertension requires special management 1

Target Blood Pressure

• General population: <140/90 mmHg 2
• High-risk patients (diabetes, renal dysfunction, cardiovascular disease): <130/80 mmHg 2
• Elderly patients (≥65 years): SBP <130 mmHg if tolerated 3
• Adults ≥85 years: More lenient target (BP <140/90 mmHg) may be considered 2

Monitoring and Follow-up

• Monthly follow-up until target BP is achieved 2
• Home blood pressure monitoring to:
  • Detect white coat or masked hypertension
  • Monitor treatment effectiveness
  • Expected home values approximately 10/5 mmHg lower than office readings 2
• Ambulatory blood pressure monitoring when clinic BP shows unusual variability 2
• Regular assessment for medication adherence and reinforcement of lifestyle modifications 2

Common Pitfalls to Avoid

1. Pseudoresistance: Exclude poor BP measurement technique, white coat effect, and nonadherence before diagnosing resistant hypertension 1

2. Medication non-adherence: Simplify regimens (single pill combinations, once-daily dosing) and educate patients 1, 2

3. Secondary causes: Screen for secondary hypertension in patients with early-onset hypertension (<30 years), resistant hypertension, or sudden deterioration in BP control 1

4. Drug interactions: Monitor for interactions with NSAIDs and potassium supplements; check renal function and potassium within 1-2 weeks of initiating ACE inhibitors and ARBs 2

5. Orthostatic hypotension: Measure standing BP in elderly patients to detect this potential complication 2

By following these comprehensive recommendations, healthcare providers can effectively manage hypertension and reduce the risk of cardiovascular morbidity and mortality in their patients.