How to manage a patient with hypertension (HTN) and a blood pressure reading of 145/94 mmHg?

Management of Hypertension with BP 145/94 mmHg

For a patient with hypertension and a blood pressure reading of 145/94 mmHg, initiate pharmacological therapy with a thiazide diuretic, either alone or in combination with other antihypertensive medications, to achieve a target BP of <140/90 mmHg. 1, 2

Initial Assessment and Classification

• BP reading of 145/94 mmHg confirms hypertension (>140/90 mmHg)
• This reading indicates Stage 1 hypertension according to most guidelines
• Mean arterial pressure of 69 mmHg is within normal range, suggesting that the elevated systolic and diastolic pressures are the primary concern

Treatment Approach

First-line Pharmacological Options:

1. Thiazide/Thiazide-like Diuretics:

   • Recommended as first-line therapy by multiple guidelines 1, 2
   • Options include:
     • Hydrochlorothiazide 12.5-25 mg daily
     • Chlorthalidone 12.5-25 mg daily (may have longer duration of action)
     • Indapamide 1.25-2.5 mg daily

2. Alternative First-line Options:

   • ACE inhibitors (e.g., lisinopril) 3
   • Angiotensin receptor blockers (e.g., losartan) 4
   • Calcium channel blockers (e.g., amlodipine) 5

Combination Therapy:

• If BP remains >140/90 mmHg after 4-6 weeks on a single agent, add a second agent
• Effective combinations include:
  • Thiazide diuretic + ACE inhibitor/ARB
  • Thiazide diuretic + calcium channel blocker
  • ACE inhibitor/ARB + calcium channel blocker

Special Considerations

Compelling Indications:

• For patients with diabetes or chronic kidney disease: Target BP <130/80 mmHg 1
• For patients with heart failure: Consider ACE inhibitors/ARBs as first-line 3
• For Black patients: Thiazide diuretics or calcium channel blockers may be more effective 4, 6

Monitoring:

• Reassess BP within 4 weeks of medication adjustment 2
• Aim to achieve target BP within 3 months 2
• Consider home or ambulatory BP monitoring to confirm office readings 2

Lifestyle Modifications

Implement alongside pharmacological therapy:

• Sodium restriction (<2g/day)
• Regular physical activity
• Weight loss if overweight/obese
• Moderation of alcohol intake
• DASH diet (rich in fruits, vegetables, and low-fat dairy products)

Management Algorithm

1. Initial BP 145/94 mmHg:

   • Start with thiazide diuretic (e.g., hydrochlorothiazide 12.5 mg daily)
   • Implement lifestyle modifications

2. If BP remains >140/90 mmHg after 4-6 weeks:

   • Increase thiazide dose (e.g., hydrochlorothiazide 25 mg daily) OR
   • Add a second agent (ACE inhibitor, ARB, or calcium channel blocker)

3. If BP remains >140/90 mmHg on dual therapy:

   • Add a third agent from a different class
   • Consider triple therapy with thiazide diuretic + ACE inhibitor/ARB + calcium channel blocker 2

4. If BP remains uncontrolled on triple therapy:

   • Consider adding spironolactone 25-50 mg daily 2
   • Consider referral to a hypertension specialist

Common Pitfalls to Avoid

• Underdosing medications: Many clinicians use suboptimal doses that fail to achieve 24-hour BP control 7
• Inadequate follow-up: Failure to reassess and adjust therapy within 4 weeks can delay achieving BP goals
• Ignoring lifestyle modifications: These should complement, not replace, pharmacological therapy
• Not considering secondary causes: If BP is difficult to control, evaluate for secondary hypertension

Remember that successful treatment to achieve a target BP of <140/90 mmHg significantly reduces cardiovascular risk 1, 6.