What is the management protocol for hypertension?

Management Protocol for Hypertension

The management of hypertension should follow a stepwise approach beginning with lifestyle modifications for all patients, followed by pharmacological therapy with a target blood pressure of <130/80 mmHg for most patients, using thiazide-like diuretics, ACE inhibitors/ARBs, or calcium channel blockers as first-line medications. 1

Diagnosis and Classification

• Blood pressure categories according to AHA/ACC 2017 guideline 1:

  • Normal: <120/80 mmHg
  • Elevated: 120-129/<80 mmHg
  • Hypertension Stage 1: 130-139/80-89 mmHg
  • Hypertension Stage 2: ≥140/90 mmHg

• Accurate diagnosis requires:

  • At least 2 readings obtained on at least 2 separate occasions
  • Proper technique with patient seated, arm at heart level
  • Consider ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to confirm diagnosis and detect white-coat hypertension 1

Treatment Goals

• General target: <130/80 mmHg for most patients 1
• Modified targets for special populations:
  • Older adults (≥65 years): <130 mmHg systolic
  • Very elderly (≥80 years): <145/90 mmHg
  • Patients with chronic kidney disease: <130/80 mmHg
  • When using home BP readings, targets should be approximately 10/5 mmHg lower than office readings 1

Step 1: Lifestyle Modifications

Lifestyle modifications are recommended for all patients with hypertension or elevated blood pressure 1, 2:

1. Weight management: Aim for BMI 20-25 kg/m² (each 1 kg weight loss reduces systolic BP by ~1 mmHg) 1
2. DASH diet: Rich in fruits, vegetables, whole grains, and low-fat dairy (3-5 mmHg reduction) 1, 2
3. Sodium reduction: Limit to <2300 mg/day (3-5 mmHg reduction) 1
4. Physical activity: 150 minutes/week of moderate-intensity aerobic exercise (3-5 mmHg reduction) 1, 3
5. Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women (3-4 mmHg reduction) 1
6. Increased potassium intake: Through fruits and vegetables (3-5 mmHg reduction) 1

Step 2: Pharmacological Therapy

When to Initiate Drug Therapy:

• Systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg 4, 1
• Systolic BP 130-139 mmHg or diastolic BP 80-89 mmHg with:
  • Target organ damage
  • Cardiovascular disease
  • Diabetes
  • 10-year cardiovascular risk >15% 4, 1

First-Line Medications:

• Thiazide or thiazide-like diuretics (preferably chlorthalidone or indapamide) 1, 5
• ACE inhibitors (e.g., lisinopril) or ARBs 1, 6
• Calcium channel blockers (e.g., amlodipine) 1, 2

Treatment Strategy:

1. Initial monotherapy for mild hypertension with low/moderate cardiovascular risk 1
2. Initial combination therapy (two drugs at low doses) for:
   • BP ≥160/100 mmHg
   • High or very high cardiovascular risk patients 1
3. Fixed-dose combinations preferred to improve adherence 1

Special Considerations:

• For coronary artery disease: RAS blockers, beta-blockers with or without CCBs 1
• For previous stroke: RAS blockers, CCBs, and diuretics 1
• For heart failure: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1
• For diabetes or albuminuria: ACE inhibitors or ARBs as first-line therapy 1

Step 3: Management of Resistant Hypertension

Resistant hypertension is defined as BP ≥130/80 mmHg despite 3 or more antihypertensive medications at optimal doses (including a diuretic) 1:

1. Verify adherence and proper BP measurement
2. Optimize diuretic therapy
3. Add spironolactone as fourth agent if serum K+ <4.5 mmol/L and eGFR >45 ml/min/1.73m²
4. Consider alternative fourth-line agents: amiloride, doxazosin, eplerenone, clonidine, or beta-blockers
5. Refer to specialist if BP remains uncontrolled 1

Follow-up and Monitoring

• Monthly follow-up until target BP is achieved 1
• Check electrolytes, creatinine, and eGFR within 1-2 weeks of initiating ACE inhibitors/ARBs 1
• Annual metabolic panel, lipid profile, and urinalysis 1
• Encourage home blood pressure monitoring 1
• Consider other cardiovascular risk reduction strategies (aspirin, statins) 4

Common Pitfalls to Avoid

• Inadequate BP measurement: Ensure proper technique and multiple readings
• Clinical inertia: Don't delay treatment intensification when goals aren't met
• Ignoring adherence issues: Simplify regimens with once-daily dosing and fixed-dose combinations
• Overlooking secondary causes: Consider screening in resistant hypertension
• Neglecting lifestyle modifications: Continue to emphasize even after starting medications
• Inappropriate drug combinations: Avoid combining ACE inhibitors with ARBs

By following this protocol, clinicians can effectively manage hypertension and reduce cardiovascular morbidity and mortality, as lowering BP by 10 mmHg decreases risk of cardiovascular events by approximately 20-30% 2.