What is the recommended treatment plan for a patient with existing hypertension?

Treatment Plan for Existing Hypertension

The recommended treatment for patients with existing hypertension should include both lifestyle modifications and appropriate pharmacological therapy, with the specific medication regimen determined by patient characteristics such as race and comorbidities. 1, 2

Initial Assessment and Classification

• Confirm hypertension diagnosis using validated automated upper arm cuff device
• Measure BP in both arms simultaneously; use the arm with higher readings
• Target BP: <130/80 mmHg for most adults; individualize for elderly based on frailty 1, 2

Step 1: Lifestyle Modifications (for all patients)

• Dietary interventions:

  • DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy)
  • Sodium restriction (<2000 mg/day)
  • Potassium supplementation (if not contraindicated)
  • Sugar restriction (<10% of energy intake)
  • Limited alcohol consumption

• Physical activity:

  • Regular aerobic exercise (150 minutes/week of moderate intensity)
  • Resistance training 2-3 times/week

• Weight management:

  • Target BMI <25 kg/m²
  • Weight loss of 5-10% for overweight/obese patients

• Smoking cessation if applicable 2, 3, 4

Step 2: Pharmacological Therapy

For Non-Black Patients:

1. Start with low-dose ACE inhibitor or ARB (e.g., losartan 50 mg daily)
2. If BP target not achieved, increase to full dose
3. Add thiazide/thiazide-like diuretic
4. Add calcium channel blocker (DHP-CCB)
5. For resistant hypertension, add spironolactone 25 mg daily 1, 2

For Black Patients:

1. Start with low-dose ARB (e.g., losartan 50 mg daily)
2. Add DHP-CCB or thiazide/thiazide-like diuretic
3. Increase to full dose
4. Add diuretic or ACE inhibitor/ARB (whichever wasn't added in step 2)
5. For resistant hypertension, add spironolactone 25 mg daily 1

Special Considerations:

• For patients with possible intravascular depletion (e.g., on diuretic therapy), start losartan at 25 mg daily 5
• For patients with left ventricular hypertrophy, consider losartan 50 mg daily + hydrochlorothiazide 12.5 mg, with potential increase to losartan 100 mg + hydrochlorothiazide 25 mg 5
• For patients with hepatic impairment, start losartan at 25 mg daily 5
• For patients with diabetes and nephropathy, start losartan at 50 mg daily with potential increase to 100 mg daily 5

Step 3: Monitoring and Follow-up

• Check BP control within 3 months of initiating therapy
• Monitor renal function and electrolytes 1-2 weeks after adding or changing medications
• Once stable, monitor every 1-3 months
• Measure BP in both sitting and standing positions to assess for orthostatic changes
• Pay special attention to potassium levels when combining medications like spironolactone with ARBs 2

Common Pitfalls and Caveats

1. Medication adherence issues:

   • Non-adherence is a common cause of resistant hypertension
   • Simplify regimen with once-daily dosing and single-pill combinations when possible
   • Avoid abrupt discontinuation of medications like clonidine or carvedilol, which can cause rebound hypertension

2. Inappropriate medication combinations:

   • Avoid combining ACE inhibitors with ARBs
   • Monitor potassium closely when using potassium-sparing diuretics with ACE inhibitors/ARBs

3. Inadequate lifestyle modifications:

   • Lifestyle changes enhance medication efficacy and should be continued even after starting pharmacotherapy
   • Sodium restriction is particularly effective when combined with antihypertensive medications

4. Insufficient monitoring:

   • Failure to achieve target BP within 3 months should prompt medication adjustment
   • Regular monitoring of renal function is essential, especially with ACE inhibitors/ARBs 1, 2

If BP remains uncontrolled despite optimal therapy with 3+ medications including a diuretic, refer to a specialist with expertise in hypertension management 1, 2.