What are the initial management guidelines for hypertension?

Initial Management Guidelines for Hypertension

The initial management of hypertension should begin with comprehensive lifestyle modifications for all patients, followed by pharmacological therapy with first-line agents including thiazide-like diuretics (preferably chlorthalidone), ACE inhibitors/ARBs, or calcium channel blockers when BP remains ≥130/80 mmHg despite lifestyle changes or for those at high cardiovascular risk. 1

Diagnosis and Blood Pressure Targets

Blood Pressure Classification

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

Measurement Technique

• Obtain at least two measurements at each visit
• Average readings from at least 2 separate occasions
• Use properly calibrated equipment with appropriate cuff size 2, 1
• Consider ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) for:
  • Unusual BP variability
  • Resistant hypertension
  • Suspected white coat hypertension
  • Symptoms suggesting hypotension 2, 1

Target Blood Pressure

• General population: <130/80 mmHg
• Older adults (≥65 years): <130 mmHg systolic
• Very elderly (≥80 years): <145/90 mmHg
• Patients with chronic kidney disease: <130/80 mmHg 1

Initial Evaluation

Required Investigations

• Urine strip test for blood and protein
• Blood electrolytes and creatinine
• Blood glucose
• Serum total:HDL cholesterol ratio
• 12-lead electrocardiograph 2

Lifestyle Modifications (First-Line Treatment)

Lifestyle modifications should be recommended to all patients with hypertension or at risk for developing hypertension:

Intervention	Approximate Systolic BP Reduction
DASH diet	3-5 mmHg
Weight loss	1 mmHg per kg lost
Sodium reduction	3-5 mmHg
Physical activity	3-5 mmHg
Alcohol moderation	3-4 mmHg
Potassium increase	3-5 mmHg

Specific Recommendations

• Weight management: Achieve ideal body weight (BMI 20-25 kg/m²) 2, 1
• Physical activity: Regular dynamic exercise (e.g., brisk walking) rather than isometric exercise (weight training) 2
• Alcohol limitation: <21 units/week for men, <14 units/week for women 2
• Dietary sodium: Reduce salt when preparing food, eliminate excessively salty foods 2
• Diet: Increase consumption of fruits and vegetables, reduce saturated fat 2, 1

Pharmacological Therapy

When to Initiate Medication

• Stage 1 hypertension (130-139/80-89 mmHg) with high cardiovascular risk or persistent elevation despite lifestyle modifications
• Stage 2 hypertension (≥140/90 mmHg) 1, 3

First-Line Medications

1. Thiazide or thiazide-like diuretics:

   • Chlorthalidone (preferred): Initial dose 25 mg once daily, may increase to 50 mg 4
   • Indapamide is an alternative 2, 1

2. ACE inhibitors:

   • Lisinopril: Initial dose 10 mg once daily, usual range 20-40 mg daily 5
   • If used with diuretics, start at 5 mg once daily 5

3. Angiotensin receptor blockers (ARBs) (if ACE inhibitor not tolerated)

4. Calcium channel blockers:

   • Amlodipine (preferred long-acting agent) 2, 1

Combination Therapy

• Consider initial combination therapy for:
  • BP ≥140/90 mmHg or >20/10 mmHg above goal
  • High cardiovascular risk patients 1
• Use fixed-dose combinations when possible to improve adherence 2, 1

Follow-up and Monitoring

• Monthly visits until blood pressure target is achieved 2, 1
• Check electrolytes, creatinine, and eGFR within 1-2 weeks of initiating ACE inhibitors/ARBs 1
• Annual metabolic panel, lipid profile, and urinalysis 1
• Consider home BP monitoring to guide medication adjustments 2, 1
• Replace 30-day with 90-day refills when possible 2

Special Considerations

Resistant Hypertension

• Defined as BP ≥130/80 mmHg despite 3 or more antihypertensive medications (including a diuretic) at optimal doses 1
• Consider adding spironolactone as fourth agent if serum K+ <4.5 mmol/L and eGFR >45 ml/min/1.73m² 1

Implementation Strategies

• Use team-based care approach
• Utilize telehealth strategies to augment office-based management
• Screen for social determinants of health 2

Common Pitfalls to Avoid

1. Inadequate BP measurement technique leading to inaccurate readings
2. Failure to identify white coat or masked hypertension
3. Insufficient lifestyle counseling before initiating medications
4. Inappropriate medication selection for patients with comorbidities
5. Inadequate follow-up after medication initiation or adjustment
6. Discontinuing lifestyle modifications after starting medications