What are the initial management steps for chronic hypertension?

Initial Management of Chronic Hypertension

The initial management of chronic hypertension should begin with lifestyle modifications for all patients, followed by first-line pharmacological therapy with thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, or long-acting dihydropyridine calcium channel blockers when blood pressure remains ≥140/90 mmHg despite lifestyle changes. 1

Lifestyle Modifications

Lifestyle modifications are the cornerstone of initial hypertension management and should be implemented for all patients:

• Dietary changes:

  • DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy)
  • Sodium restriction to approximately 2g per day (5g salt)
  • Limit free sugar consumption, especially sugar-sweetened beverages
  • Potassium supplementation through diet 1

• Physical activity:

  • Moderate-intensity aerobic exercise ≥150 minutes/week (30 min, 5-7 days/week) or 75 minutes of vigorous exercise per week
  • Resistance training 2-3 times/week 1

• Weight management:

  • Target healthy BMI (20-25 kg/m²)
  • Target waist circumference <94 cm in men, <80 cm in women 1

• Alcohol limitation:

  • Maximum 100g/week of pure alcohol (approximately 7-12 standard drinks) 1

• Complete cessation of tobacco use 1

Pharmacological Therapy

When blood pressure remains ≥140/90 mmHg despite lifestyle modifications, initiate pharmacological therapy:

First-Line Medications (choose one based on patient characteristics):

1. Thiazide/thiazide-like diuretics:

   • Chlorthalidone: Initial dose 25 mg once daily in the morning with food
   • Can increase to 50 mg daily if insufficient response 2

2. ACE inhibitors:

   • Lisinopril: Initial dose 10 mg once daily
   • Usual dosage range: 20-40 mg per day as a single daily dose
   • If used with diuretics, start at 5 mg once daily 3

3. ARBs:

   • Consider in patients who cannot tolerate ACE inhibitors (e.g., due to cough)

4. Long-acting dihydropyridine calcium channel blockers:

   • Particularly beneficial for Black patients 1

Patient-Specific Considerations:

• Heart failure patients: Prefer ACE inhibitors, ARBs, or beta-blockers
• Chronic kidney disease: Prefer ACE inhibitors to slow disease progression
• Diabetic patients with albuminuria: Prefer ACE inhibitors or ARBs
• Black patients: Consider calcium channel blockers as first-line
• Elderly patients: Use more gradual dose titration with careful monitoring for orthostatic hypotension
• Pregnant women: Avoid ARBs due to risk of fetal damage 1

Treatment Goals

Target blood pressure should be individualized based on patient characteristics:

• General population: <140/90 mmHg
• Patients with cardiovascular disease: <130 mmHg systolic
• High-risk patients (diabetes, CKD, high CVD risk): <130 mmHg systolic
• Adults under 65 years: 120-129 mmHg systolic if tolerated
• Adults 65 years and older: 130-139 mmHg systolic
• Elderly patients (>80 years): <140/80 mmHg 1

Follow-Up and Monitoring

• Follow-up within 2-4 weeks after starting or changing medications
• Monthly follow-up until target blood pressure is reached
• Once controlled, follow-up every 3-5 months
• Monitor serum creatinine/eGFR and potassium at baseline and at least annually for patients on ACE inhibitors, ARBs, or diuretics 1

Common Pitfalls to Avoid

1. Inadequate lifestyle counseling: Many clinicians rush to medication without sufficient emphasis on lifestyle changes
2. Inappropriate combination therapy: Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury without added benefit
3. Insufficient follow-up: Failure to monitor and adjust therapy leads to suboptimal blood pressure control
4. Overlooking patient-specific factors: Treatment should be tailored based on comorbidities, age, race, and pregnancy status
5. Ignoring orthostatic hypotension: Particularly important in elderly patients who require more gradual dose titration

Remember that more than 70% of hypertensive patients will eventually require at least two antihypertensive agents for adequate blood pressure control 1, so be prepared to add a second agent from a different class if monotherapy is insufficient.