What is the recommended approach to managing a patient with hypertension?

Management of Hypertension: A Comprehensive Approach

The recommended approach to managing hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy with a combination of drugs that typically includes a renin-angiotensin system blocker (ACE inhibitor or ARB), a calcium channel blocker, and/or a thiazide-like diuretic, with a target blood pressure of <130/80 mmHg for most adults. 1, 2

Initial Assessment and Risk Stratification

• Accurately measure BP using standardized techniques (seated position, appropriate cuff size, after 5 minutes of rest)
• Confirm diagnosis with out-of-office BP measurements (home BP monitoring or ambulatory BP monitoring)
• Assess cardiovascular risk factors and target organ damage
• Screen for secondary causes of hypertension in patients with:
  • Sudden onset of hypertension
  • Resistant hypertension (BP uncontrolled on ≥3 medications)
  • Age <30 years without risk factors
  • Signs/symptoms suggesting secondary causes

Step 1: Lifestyle Modifications (For All Patients)

• Dietary changes:
  • Adopt DASH (Dietary Approaches to Stop Hypertension) eating pattern
  • Reduce sodium intake (<2300 mg/day)
  • Increase potassium intake (unless contraindicated)
• Physical activity: 150 minutes of moderate-intensity aerobic activity per week
• Weight management: Target BMI <25 kg/m²
• Alcohol moderation: Limit to ≤2 drinks/day for men and ≤1 drink/day for women
• Smoking cessation: Provide resources and support for quitting

Step 2: Pharmacological Therapy

Initial Drug Selection:

• First-line options 1, 2:
  • ACE inhibitor (e.g., lisinopril) or ARB
  • Calcium channel blocker (dihydropyridine type, e.g., amlodipine)
  • Thiazide or thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide)

Treatment Algorithm:

1. Stage 1 Hypertension (130-139/80-89 mmHg):

   • Start with monotherapy if low cardiovascular risk
   • Consider dual therapy (preferably single-pill combination) if high cardiovascular risk

2. Stage 2 Hypertension (≥140/90 mmHg):

   • Initiate dual therapy with two first-line agents (preferably as single-pill combination)
   • Common combinations: ACE inhibitor/ARB + calcium channel blocker or ACE inhibitor/ARB + thiazide diuretic

3. Resistant Hypertension:

   • Add spironolactone as fourth-line agent (if potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m²)
   • Consider referral to hypertension specialist

Special Populations:

• Black patients: Calcium channel blocker or thiazide diuretic preferred as initial therapy 3
• Elderly (≥65 years): Same medications but with more careful titration; target SBP <130 mmHg if tolerated 1
• Diabetes: ACE inhibitor or ARB preferred as first-line therapy
• Chronic kidney disease: ACE inhibitor or ARB preferred
• Metabolic syndrome: ACE inhibitor or ARB preferred; avoid beta-blockers unless specifically indicated 1

Step 3: Team-Based Care and Follow-Up

• Implement team-based care approach involving physicians, nurses, pharmacists, and other healthcare providers 1

• Utilize telehealth strategies and electronic health records to improve BP control 1

• Follow-up frequency:

  • Monthly visits until BP target is reached
  • Every 3-6 months once BP is controlled
  • More frequent monitoring for patients with resistant hypertension or organ damage

• Promote medication adherence:

  • Use once-daily dosing when possible
  • Consider single-pill combinations
  • Assess adherence at each visit using a non-judgmental approach
  • Motivational interviewing techniques to enhance adherence 1

Common Pitfalls to Avoid

1. Inadequate BP measurement: Ensure proper technique and equipment
2. Clinical inertia: Don't delay intensification of therapy when BP remains above target
3. Ignoring white coat or masked hypertension: Use out-of-office BP measurements to confirm diagnosis
4. Overlooking medication adherence: Always consider non-adherence before diagnosing resistant hypertension
5. Neglecting lifestyle modifications: Continue to emphasize even after starting medications
6. Inappropriate drug combinations: Avoid combining ACE inhibitors with ARBs

Patient-Centered Approach

• Engage patients in shared decision-making about treatment goals and options 1
• Communicate BP targets and treatment benefits clearly
• Address patient concerns about medication side effects
• Consider patient preferences, costs, and barriers to adherence when selecting medications
• Provide educational resources about hypertension and its management

By following this comprehensive approach to hypertension management, clinicians can effectively reduce blood pressure, minimize cardiovascular risk, and improve patient outcomes.