What is the recommended management for a 58-year-old with hypertension (high blood pressure) and average blood pressure readings of 140/90 mmHg in the morning and 148/96 mmHg in the evening according to National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries (CKS) guidelines?

Management of Hypertension in a 58-Year-Old with BP Readings of 140/90 Morning and 148/96 Evening According to NICE Guidelines

This 58-year-old patient with average blood pressure readings of 140/90 mmHg in the morning and 148/96 mmHg in the evening should immediately start both lifestyle interventions and drug treatment with a low-dose ACE inhibitor or ARB as first-line therapy, according to current hypertension guidelines.

Blood Pressure Classification and Assessment

• The patient's BP readings (140/90 mmHg morning, 148/96 mmHg evening) classify as Grade 1-2 Hypertension 1
• At 58 years old, this patient falls into the high-risk category requiring immediate pharmacological intervention 1
• Before initiating treatment, confirm the diagnosis with:
  • Multiple office BP measurements
  • Consider ambulatory or home BP monitoring to rule out white-coat hypertension 1

Treatment Approach

Immediate Interventions

1. Lifestyle modifications:

   • Sodium restriction (<100 mmol/day)
   • 30-60 minutes of aerobic exercise 4-7 days/week
   • Maintain healthy BMI (18.5-24.9 kg/m²) and waist circumference (<102 cm for men, <88 cm for women)
   • Limit alcohol consumption (≤14 units/week for men, ≤9 units/week for women)
   • Follow DASH diet (emphasizing fruits, vegetables, low-fat dairy, reduced saturated fat)
   • Consider stress management techniques 1, 2

2. Pharmacological treatment:

   • Start with low-dose ACE inhibitor or ARB (for non-Black patients)
   • For Black patients, start with calcium channel blocker or thiazide/thiazide-like diuretic 1, 2
   • Aim for once-daily dosing to improve adherence 2

Treatment Algorithm

1. First-line: Low-dose ACE inhibitor or ARB
2. If BP remains uncontrolled: Increase to full dose
3. If still uncontrolled: Add calcium channel blocker
4. If still uncontrolled: Add thiazide/thiazide-like diuretic
5. If resistant hypertension: Consider adding spironolactone or alternatives (amiloride, doxazosin, eplerenone, clonidine, or beta-blocker) 1

Treatment Targets and Monitoring

• Target BP: <130/80 mmHg 1, 2
• Initial goal: Reduce BP by at least 20/10 mmHg 1
• Monitoring schedule:
  • Check BP within 1-2 weeks of starting or adjusting medication 2
  • Aim to achieve target BP within 3 months 1
  • Monitor renal function and electrolytes within 2-4 weeks of starting ACE inhibitor/ARB 2
  • Regular follow-up to assess medication adherence and efficacy

Common Pitfalls to Avoid

1. Delayed treatment: Given the patient's age (58) and BP readings, immediate pharmacological intervention is warranted rather than waiting for lifestyle modifications to take effect 1, 2

2. Inadequate monitoring: Failure to check BP regularly and monitor for medication side effects can lead to suboptimal control

3. Medication non-adherence: Use once-daily dosing regimens and single-pill combinations where possible to improve adherence 1

4. Overlooking secondary causes: If BP remains uncontrolled despite appropriate therapy, consider secondary causes of hypertension 2

5. White-coat effect: Confirm office readings with home or ambulatory BP monitoring before making major treatment decisions 1

By following this evidence-based approach, the patient's hypertension can be effectively managed to reduce cardiovascular risk and prevent end-organ damage.