What is the treatment plan for stable hypertension?

Primary Care Template for Treatment of Stable Hypertension

The first-line treatment for stable hypertension should include lifestyle modifications and pharmacotherapy with thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers, with medication selection based on patient characteristics and comorbidities. 1

Initial Assessment and Risk Stratification

• Determine hypertension stage:

  • Stage 1: SBP 130-139 mmHg or DBP 80-89 mmHg
  • Stage 2: SBP ≥140 mmHg or DBP ≥90 mmHg

• Assess cardiovascular risk factors:

  • Age, sex, smoking status, diabetes, dyslipidemia
  • Family history of premature cardiovascular disease
  • Target organ damage (left ventricular hypertrophy, CKD, retinopathy)

• Establish BP target:

  • Most adults: <130/80 mmHg 1, 2
  • Minimum acceptable level: <150/90 mmHg for elderly patients who cannot tolerate lower targets 1
  • Patients with diabetes, CKD, or established CVD: <130/80 mmHg 1

Lifestyle Modifications (First-Line for All Patients)

1. Dietary Approach:

   • DASH diet: rich in fruits, vegetables, whole grains, low-fat dairy 1
   • Sodium restriction: <2,300 mg/day 1
   • Increase potassium-rich foods 1

2. Physical Activity:

   • 150 minutes of moderate-intensity aerobic exercise per week 1
   • At least 30 minutes on most days of the week

3. Weight Management:

   • Target BMI of 20-25 kg/m² 1
   • Waist-to-height ratio <0.5 1

4. Alcohol Limitation:

   • Men: ≤2 standard drinks/day
   • Women: ≤1.5 standard drinks/day 1

5. Smoking Cessation:

   • Provide counseling and pharmacotherapy as needed

Pharmacologic Treatment Algorithm

Initial Therapy Selection

1. Stage 1 Hypertension:

   • Start with a single agent, then titrate dose 1
   • First-line options:
     • ACE inhibitor (e.g., lisinopril) 1, 3
     • ARB (e.g., losartan) 1, 4
     • Thiazide diuretic (preferably chlorthalidone) 1
     • Calcium channel blocker (e.g., amlodipine) 1

2. Stage 2 Hypertension (BP >20/10 mmHg above target):

   • Initial combination therapy with two agents from different classes 1
   • Common combinations:
     • ACE inhibitor + thiazide diuretic
     • ARB + thiazide diuretic
     • CCB + ACE inhibitor or ARB

Patient-Specific Considerations

• Black patients:

  • CCBs or thiazide diuretics preferred over ACE inhibitors 1

• Patients with CKD or albuminuria:

  • ACE inhibitor or ARB as first-line 1
  • Target BP <130/80 mmHg 1

• Elderly patients (>80 years) or frail:

  • Once-daily dosing
  • Single-pill combinations when possible
  • Start at lower doses and titrate slowly 1

• Women of childbearing potential:

  • Avoid ACE inhibitors and ARBs (teratogenic) 1
  • Consider CCBs or labetalol if planning pregnancy

• Patients with heart failure:

  • ACE inhibitors, ARBs, beta-blockers, or spironolactone 3, 5

Monitoring and Follow-up

1. Initial Follow-up:

   • Schedule follow-up within 2-4 weeks after starting or changing medications 1
   • Assess BP control, medication adherence, and side effects

2. Laboratory Monitoring:

   • Baseline: Electrolytes, creatinine/eGFR, fasting glucose, lipid panel
   • For patients on ACE inhibitors, ARBs, or diuretics: Check serum creatinine/eGFR and potassium at least annually 1

3. Long-term Follow-up:

   • Stable patients: Monitor every 3-6 months
   • Annual comprehensive assessment for stable patients 1

Treatment Intensification

1. If BP remains above target:

   • Confirm adherence to medications and lifestyle modifications
   • Increase medication dose to maximum tolerated
   • Add a medication from a different class
   • Consider referral to hypertension specialist if BP remains uncontrolled on ≥3 medications

2. Medication Adjustment Considerations:

   • Avoid combining ACE inhibitors with ARBs (increased risk of hyperkalemia and acute kidney injury) 1
   • Beta-blockers are not recommended as first-line unless specific indications exist (e.g., coronary artery disease, heart failure) 1
   • Alpha-blockers are not recommended as first-line therapy 1

Common Pitfalls to Avoid

• Inadequate dose titration: Ensure medications are titrated to effective doses before adding new agents
• Ignoring adherence issues: Address barriers to medication adherence
• Overlooking secondary causes: Consider screening for secondary hypertension if BP is resistant to treatment
• White coat hypertension: Consider home BP monitoring or ambulatory BP monitoring to confirm diagnosis
• Therapeutic inertia: Don't delay intensification of therapy when BP remains above target
• Drug interactions: Review all medications, including over-the-counter drugs and supplements

Remember that blood pressure control is part of comprehensive cardiovascular risk management, including lipid control, diabetes management, and antithrombotic therapy when indicated 4, 3.