What are the recommended management strategies for hypertension?

Management of Hypertension

The management of hypertension should target a systolic blood pressure of 120-129 mmHg for most patients, with individualized targets based on age, comorbidities, and tolerability. 1

Blood Pressure Targets

• General population: Initial target <140/90 mmHg, optimal target <140/85 mmHg 2
• High-risk patients (diabetes, chronic kidney disease, established cardiovascular disease): Target <130/80 mmHg 2
• Older patients (≥65 years): Target systolic BP 130-139 mmHg 2
• Very elderly (≥85 years): More lenient target of <140/90 mmHg 2
• CKD patients with eGFR >30 mL/min/1.73 m²: Target systolic BP 120-129 mmHg 1

Lifestyle Modifications (First-line for All Patients)

1. Weight management: Achieve and maintain healthy BMI (20-25 kg/m²) 2
2. Physical activity: 30 minutes of moderate aerobic exercise 5-7 days/week plus resistance training 2-3 times weekly 2
3. Dietary modifications:
   • Salt restriction to 5-6g per day 2
   • Increased consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids 2
   • Reduced consumption of red meat 2
4. Alcohol limitation: Men <14 units/week, women <8 units/week 2
5. Smoking cessation 2

These lifestyle modifications can reduce systolic BP by approximately 5 mmHg, which can decrease mortality due to coronary heart disease by 9%, stroke-related mortality by 14%, and all-cause mortality by 7% 3.

Pharmacological Therapy

Initial Drug Selection

First-line medications include:

• Thiazide or thiazide-like diuretics
• ACE inhibitors or ARBs
• Calcium channel blockers (CCBs) 2

Special Populations

• Black patients: Initial therapy should include a diuretic or CCB, either alone or with a RAS blocker 1
• Diabetes with proteinuria: RAS blockers (ACE inhibitors or ARBs) are recommended 1
• Heart failure with reduced ejection fraction: Combination of ACE inhibitor/ARB, beta-blocker, diuretic, MRA, and SGLT2 inhibitors 1
• Heart failure with preserved ejection fraction: SGLT2 inhibitors recommended 1
• Post-stroke: Target systolic BP 120-130 mmHg 1

Treatment Algorithm

1. Stage 1 hypertension (BP 140-159/90-99 mmHg):

   • Start with lifestyle modifications for 3-6 months
   • If target not achieved or patient has high cardiovascular risk, initiate single-agent therapy

2. Stage 2 hypertension (BP ≥160/100 mmHg):

   • Start with lifestyle modifications AND pharmacological therapy
   • Consider initial dual therapy at low doses 2

3. Resistant hypertension (uncontrolled on 3 drugs):

   • Add spironolactone as fourth agent
   • If not tolerated, consider eplerenone, amiloride, higher dose thiazide/thiazide-like diuretic, or loop diuretic
   • Alternative options: bisoprolol or doxazosin 1
   • Consider renal denervation in specialized centers for truly resistant cases 1

Monitoring and Follow-up

• Regular follow-up appointments (monthly until target BP is achieved)
• Home blood pressure monitoring to detect white coat hypertension and monitor treatment effectiveness
• Consider ambulatory blood pressure monitoring when clinic readings show unusual variability 2

Adherence Strategies

• Simplify regimens when possible (once-daily dosing or fixed-dose combinations)
• Use effective behavioral and motivational strategies to improve adherence 2

Additional Considerations

• Consider evaluation for secondary causes of hypertension when there is sudden onset or worsening of hypertension, resistance to multidrug regimen, young age, or presence of clinical clues 2
• For patients with hypertension and high cardiovascular risk, consider adding aspirin 75mg daily and statin therapy 2

Effective hypertension management significantly reduces the risk of cardiovascular events, with a 10 mmHg reduction in systolic BP decreasing the risk of cardiovascular events by approximately 20-30% 4.