How do I manage hypertension?

Management of Hypertension

The treatment of hypertension should begin with lifestyle modifications for all patients, with prompt initiation of pharmacological therapy for those with blood pressure ≥140/90 mmHg or ≥130/80 mmHg in high-risk individuals. 1

Initial Assessment and Classification

Blood pressure categories according to the American Heart Association 1:

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

Lifestyle Modifications

Lifestyle modifications are essential for all patients with BP >120/80 mmHg and include 2, 1:

• Weight loss: Target BMI 20-25 kg/m²; reduces systolic BP by approximately 1 mmHg per kg lost
• DASH diet: Increases fruits, vegetables, and low-fat dairy; reduces systolic BP by 3-5 mmHg
• Sodium restriction: <2,300 mg/day; reduces systolic BP by 3-5 mmHg
• Increased potassium intake: 3,500-5,000 mg/day; reduces systolic BP by 3-5 mmHg
• Physical activity: Regular aerobic exercise; reduces systolic BP by 3-5 mmHg
• Alcohol moderation: Reduces systolic BP by 3-4 mmHg

Pharmacological Therapy

When to Initiate Medication

• BP ≥140/90 mmHg: Initiate pharmacological therapy along with lifestyle modifications 2
• BP ≥160/100 mmHg: Promptly initiate two drugs or a single-pill combination 2
• BP 130-139/80-89 mmHg: Consider medication if patient has diabetes, cardiovascular disease, or 10-year ASCVD risk ≥15% 2, 1

First-Line Medications

The following drug classes have demonstrated cardiovascular event reduction 2, 1, 3:

1. Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide)
2. ACE inhibitors (e.g., lisinopril) or ARBs (e.g., losartan)
3. Calcium channel blockers (e.g., amlodipine)

Special Considerations

• Diabetes with nephropathy: ARBs like losartan are indicated to reduce progression of nephropathy 4
• Heart failure: ACE inhibitors like lisinopril are indicated to reduce symptoms 5
• Left ventricular hypertrophy: Losartan is indicated to reduce stroke risk (except in Black patients) 4
• Post-myocardial infarction: Lisinopril is indicated for mortality reduction 5
• Black patients: May have smaller BP-lowering response to ACE inhibitors/ARBs as monotherapy 4, 5

Treatment Algorithm

1. For BP 120-139/80-89 mmHg:

   • Implement lifestyle modifications
   • Monitor BP regularly
   • Consider medication for high-risk patients (diabetes, CVD, high ASCVD risk)

2. For BP 140-159/90-99 mmHg:

   • Implement lifestyle modifications
   • Start with a single antihypertensive agent
   • Preferred options: thiazide diuretic, ACE inhibitor/ARB, or calcium channel blocker

3. For BP ≥160/100 mmHg:

   • Implement lifestyle modifications
   • Initiate two-drug combination therapy
   • Preferred combinations: ACE inhibitor/ARB + calcium channel blocker or ACE inhibitor/ARB + thiazide diuretic

Treatment Goals

• General population: <130/80 mmHg 1
• Older adults (≥65 years): <130 mmHg systolic if tolerated 1
• Very elderly (≥85 years): Consider more lenient target (<140/90 mmHg) 1
• Diabetes or kidney disease: <130/80 mmHg 2, 1

Monitoring and Follow-up

• Monthly visits until BP target is achieved 1
• Monitor electrolytes, creatinine, and eGFR within 1-2 weeks of initiating ACE inhibitors/ARBs 1
• Encourage home BP monitoring to guide medication adjustments 1
• Assess medication adherence and side effects at each visit 1

Common Pitfalls to Avoid

1. Inadequate initial therapy: For BP ≥160/100 mmHg, start with two medications
2. Ignoring lifestyle modifications: These enhance medication efficacy and provide additional health benefits
3. Inappropriate combination therapy: Avoid combining ACE inhibitors with ARBs
4. Neglecting comorbidities: Consider specific drug classes based on coexisting conditions
5. Insufficient monitoring: Regular follow-up is essential for titration and adherence assessment

By following this evidence-based approach, hypertension can be effectively controlled, reducing the risk of cardiovascular events, primarily strokes and myocardial infarctions 4, 5, 3.