What is the initial management and treatment for hypertension?

Initial Management and Treatment of Hypertension

The initial management of hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy for those with blood pressure ≥140/90 mmHg or those with lower blood pressure but with target organ damage, cardiovascular disease, diabetes, or high cardiovascular risk 1, 2.

Lifestyle Modifications (First-line for all patients)

Lifestyle modifications are recommended for all patients with blood pressure >120/80 mmHg and include:

• Weight loss when indicated
• DASH-style eating pattern including:
  • Reducing sodium intake (<2,300 mg/day)
  • Increasing potassium intake
  • Increasing consumption of fruits and vegetables (8-10 servings/day)
  • Increasing low-fat dairy products (2-3 servings/day)
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week
• Alcohol moderation: No more than 2 drinks/day for men, 1 drink/day for women
• Smoking cessation 1, 2, 3

These lifestyle modifications can lower systolic blood pressure by:

• DASH diet: 3-11 mmHg
• Weight loss: 1 mmHg per kg lost
• Sodium reduction: 3-6 mmHg
• Physical activity: 3-8 mmHg
• Alcohol moderation: 3-4 mmHg 2, 4

Pharmacological Therapy

When to Initiate Medication

1. Immediate treatment for:

   • Sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg 2

2. Treatment indicated for sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg when:

   • Target organ damage is present
   • Established cardiovascular disease exists
   • Diabetes is present
   • 10-year cardiovascular risk is high 2

Initial Medication Selection

The choice of initial antihypertensive medication depends on blood pressure level and comorbidities:

1. For BP between 130/80 mmHg and 150/90 mmHg:

   • Begin with a single drug from one of these classes:
     • ACE inhibitors
     • ARBs
     • Thiazide-like diuretics
     • Dihydropyridine calcium channel blockers 1

2. For BP ≥150/90 mmHg:

   • Initial treatment with two antihypertensive medications is recommended 1
   • Single-pill combinations may improve adherence 1

Special Populations

• Patients with diabetes and albuminuria (UACR ≥30 mg/g):

  • ACE inhibitor or ARB is recommended first-line 1

• Patients with coronary artery disease:

  • ACE inhibitor or ARB is recommended first-line 1

• Black patients:

  • Initial treatment should include a diuretic or calcium channel blocker 1

• Pregnancy:

  • ACE inhibitors, ARBs, MRAs, direct renin inhibitors, and neprilysin inhibitors are contraindicated 1

Blood Pressure Targets

• General target: <130/80 mmHg 1, 4
• Minimum acceptable control (audit standard): <150/90 mmHg 2
• For patients with diabetes or CKD: Systolic BP 130-139 mmHg 1

Monitoring and Follow-up

• Allow at least 4 weeks to observe full response to medication changes 2
• Monitor serum creatinine/eGFR and potassium levels:
  • At baseline
  • 7-14 days after initiation or dose change of ACE inhibitors, ARBs, or MRAs
  • At least annually thereafter 1
• Schedule follow-up visits every 2-4 weeks until BP goal is achieved, then every 3-6 months 2

Management of Resistant Hypertension

Resistant hypertension is defined as BP ≥140/90 mmHg despite therapy with three antihypertensive drugs including a diuretic 1.

For resistant hypertension:

1. Reinforce lifestyle measures, especially sodium restriction
2. Add low-dose spironolactone to existing treatment
3. If intolerant to spironolactone, add eplerenone, amiloride, higher dose thiazide/thiazide-like diuretic, or a loop diuretic
4. Consider adding bisoprolol or doxazosin 1

Common Pitfalls to Avoid

• Inadequate dosing: Ensure medications are titrated to effective doses
• Poor adherence: Address barriers such as cost, side effects, and complexity of regimen
• White coat hypertension: Consider ambulatory BP monitoring when clinic BP shows unusual variability
• Secondary hypertension: Consider in resistant cases or young adults
• Medication interactions: Be aware of potential interactions with NSAIDs, decongestants, and certain supplements
• Orthostatic hypotension: Monitor for this especially in elderly patients when initiating therapy

By following this structured approach to hypertension management, clinicians can effectively reduce cardiovascular risk and improve patient outcomes.