What are the steps for managing hypertension?

Hypertension Stepwise Management

Hypertension management should begin with lifestyle modifications for all patients, followed by pharmacological therapy with first-line agents (ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics) when needed, with subsequent addition of medications from different classes if blood pressure remains uncontrolled. 1

Initial Assessment and Treatment Approach

Step 1: Lifestyle Modifications

Lifestyle modifications should be instituted in all patients with hypertension and include:

• Weight reduction in overweight individuals (5-20 mmHg reduction per 10kg weight loss)
• DASH diet rich in fruits, vegetables, whole grains (8-14 mmHg reduction)
• Sodium restriction to 2.4g sodium per day (2-8 mmHg reduction)
• Regular physical activity - 150 minutes/week of moderate-intensity exercise (4-9 mmHg reduction)
• Moderation of alcohol consumption (2-4 mmHg reduction)
• Smoking cessation 1, 2

Step 2: Pharmacological Therapy Initiation

• For high-normal BP or grade 1 hypertension without high-risk factors: Start with lifestyle modifications for 3-6 months; if BP remains uncontrolled, initiate pharmacological therapy
• For grade 1 hypertension with high-risk factors or higher grades of hypertension: Immediately initiate both lifestyle modifications and pharmacological therapy 1

Medication Selection Algorithm

First-Line Agents (Step 2)

Choose a single agent from one of these classes:

• ACE inhibitors (e.g., lisinopril)
• ARBs (e.g., losartan)
• Calcium channel blockers (dihydropyridines)
• Thiazide or thiazide-like diuretics 1

Special population considerations:

• Diabetic patients: Prefer ACE inhibitors or ARBs, especially with albuminuria
• Heart failure patients: Prefer ACE inhibitors, ARBs, or beta-blockers
• CKD patients: Prefer ACE inhibitors to slow kidney disease progression
• Black patients: May benefit from calcium channel blocker as first-line therapy
• Elderly patients: Require more gradual dose titration with careful monitoring for orthostatic hypotension 1

Step 3: Dual Therapy

If blood pressure remains uncontrolled on a single agent at optimal dose:

• Add a second agent from a different class
• Preferred combinations:
  • ACE inhibitor or ARB + calcium channel blocker
  • ACE inhibitor or ARB + thiazide diuretic
  • Calcium channel blocker + thiazide diuretic 1

Important caveat: Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury without added benefit 1

Step 4: Triple Therapy

If blood pressure remains uncontrolled on dual therapy:

• Add a third agent: RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB + thiazide/thiazide-like diuretic 1

Step 5: Resistant Hypertension

For patients not achieving target BP on triple therapy:

• Add a fourth agent (typically spironolactone, other potassium-sparing diuretic, or beta-blocker)
• Consider secondary causes of hypertension
• Refer to hypertension specialist 1

Blood Pressure Targets

• General population: <140/90 mmHg
• High-risk patients (diabetes, CKD, high CVD risk): <130/80 mmHg 1

The European Society of Cardiology recommends that blood pressure be lowered at least to below 140/90 mmHg in all hypertensive patients and that lower values be pursued if tolerated 2

Monitoring and Follow-up

• Monthly follow-up after medication initiation or changes until target BP is reached
• Monitor serum creatinine/eGFR and potassium at baseline and at least annually for patients on ACE inhibitors, ARBs, or diuretics
• Follow-up every 3-5 months for patients with controlled blood pressure 1

Clinical Pearls and Pitfalls

• More than 70% of hypertensive patients will eventually require at least two antihypertensive agents for adequate blood pressure control 1
• Lowering blood pressure reduces the risk of cardiovascular events, primarily strokes and myocardial infarction 3, 4
• Control of high blood pressure should be part of comprehensive cardiovascular risk management, including lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake 3, 4
• Pregnant women should avoid ARBs due to the risk of fetal damage 1
• The largest and most consistent cardiovascular outcome benefit has been a reduction in the risk of stroke, but reductions in myocardial infarction and cardiovascular mortality have also been seen regularly 5

Remember that lifestyle modifications should be continued even when pharmacological therapy is initiated, as they enhance the efficacy of antihypertensive medications 5, 6.