What are the recommended management strategies for hypertension?

Management of Hypertension

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

Blood Pressure Thresholds for Treatment

When to Initiate Drug Treatment

• Initiate antihypertensive drug treatment if:
  • Sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg despite lifestyle modifications 2
  • Sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg with:
    • Target organ damage
    • Established cardiovascular disease
    • Diabetes mellitus
    • 10-year cardiovascular disease risk ≥20% 2, 1
  • For patients with diabetes: Initiate if systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg 2

Blood Pressure Targets

• General population:

  • Initial target: <140/90 mmHg
  • Optimal target: <140/85 mmHg 2, 1
  • Minimum acceptable control (audit standard): <150/90 mmHg 2

• High-risk patients (diabetes, chronic renal disease, established cardiovascular disease):

  • Target: <130/80 mmHg 2, 1, 3
  • Audit standard: <140/80 mmHg 2

• Older patients (≥65 years):

  • Target systolic BP: 130-139 mmHg 1
  • Consider more lenient targets (<140/90 mmHg) for very elderly patients (≥85 years) 1

Lifestyle Modifications

Lifestyle modifications should be implemented for all patients with hypertension and those with borderline or high-normal blood pressure 2, 1:

1. Physical Activity:

   • 30 minutes of moderate dynamic aerobic exercise 5-7 days per week
   • Resistance training 2-3 times weekly 1, 4

2. Weight Management:

   • Target BMI of 20-25 kg/m²
   • Waist circumference <94 cm in men and <80 cm in women 1

3. Dietary Modifications:

   • Salt restriction to 5-6 g per day
   • Increased consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids
   • Low consumption of red meat
   • Low-fat dairy products 1

4. Alcohol Limitation:

   • Men: <14 units/week
   • Women: <8 units/week 1

5. Smoking Cessation for all patients with hypertension 1

Pharmacological Therapy

First-Line Medications

For most patients without compelling indications for other drugs, first-line therapy includes:

• Thiazide or thiazide-like diuretics
• ACE inhibitors or ARBs
• Calcium channel blockers 2, 1, 3

Treatment Algorithm

1. Initial Therapy:

   • For BP <160/100 mmHg: Start with monotherapy
   • For BP ≥160/100 mmHg or high CV risk: Start with low-dose combination therapy of two drugs 1

2. If BP Not at Target:

   • Increase to full-dose monotherapy OR
   • Add a second agent from a different class 1

3. If Still Not Controlled:

   • Triple therapy: Usually combining an ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 1

4. Resistant Hypertension:

   • Add a fourth agent or consider specialist referral
   • Consider secondary causes of hypertension 2, 1

Monitoring and Follow-up

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

Special Considerations

Secondary Hypertension Evaluation

Consider evaluation when:

• Sudden onset or worsening of hypertension
• Resistance to multidrug regimen (≥3 drugs)
• Young age (any hypertension <20 years; needing treatment <30 years)
• Clinical clues suggesting secondary causes 2, 1

Improving Adherence

• Simplify regimens when possible (once-daily dosing or fixed-dose combinations)
• Effective behavioral and motivational strategies 2, 1
• Consider cultural, social, and economic factors that may influence adherence 2

Additional Cardiovascular Risk Reduction

• Aspirin: 75 mg daily for secondary prevention and primary prevention in patients >50 years with controlled BP (<150/90 mmHg) and 10-year CVD risk ≥20% 2
• Statins: For all patients with hypertension complicated by cardiovascular disease and for primary prevention in those with 10-year CVD risk ≥20% 2

Most patients with hypertension will require at least two blood pressure-lowering drugs to achieve recommended goals. When no disadvantages of cost exist, fixed drug combinations are recommended to improve adherence 2, 1, 3.