What is the initial management approach for a patient with newly diagnosed hypertension and a blood pressure reading of 154/90 mmHg?

Management of Newly Diagnosed Hypertension with BP 154/90 mmHg

The initial management for newly diagnosed hypertension with a blood pressure of 154/90 mmHg should include both immediate lifestyle modifications and pharmacological therapy, as this reading falls into Stage 2 hypertension requiring prompt treatment. 1, 2

Confirming the Diagnosis

Before initiating treatment, it's important to confirm the diagnosis:

• For BP readings of 140-159/90-99 mmHg, confirmation should be based on out-of-office BP measurement with ABPM (ambulatory blood pressure monitoring) and/or HBPM (home blood pressure monitoring) 1
• If these measurements are not logistically feasible, diagnosis can be made on repeated office BP measurements on more than one visit 1
• For this specific reading (154/90 mmHg), confirmation should be done as soon as possible, preferably within 1 month 1

Initial Management Approach

Immediate Steps

1. Start lifestyle modifications immediately 1, 2:

   • Weight management to achieve/maintain healthy BMI (18.5-24.9 kg/m²)
   • DASH diet with sodium restriction (<2,300 mg/day)
   • Increased potassium intake (8-10 servings of fruits/vegetables daily)
   • Physical activity (≥150 minutes of moderate-intensity aerobic activity weekly)
   • Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women)

2. Start pharmacological therapy immediately 1, 2:

   • This BP reading (154/90 mmHg) falls into Grade 2 hypertension category, requiring immediate drug treatment

Pharmacological Therapy Selection

For non-Black patients:

• Start with low-dose ACE inhibitor or ARB 2
  • Lisinopril: Initial dose 10 mg once daily, usual range 20-40 mg daily 3
  • OR Losartan: Initial dose 50 mg once daily, can be increased to 100 mg daily as needed 4

For Black patients:

• Start with calcium channel blocker or thiazide/thiazide-like diuretic 2
• If using ARB, consider losartan 50 mg once daily 4

Monitoring and Follow-up

1. Short-term monitoring:

   • Check BP within 1-2 weeks of starting medication 2
   • Monitor for medication side effects
   • For patients on ACE inhibitors/ARBs, check serum creatinine and potassium within 7-14 days 2

2. Target BP goal:

   • Aim to reduce BP by at least 20/10 mmHg 1
   • Target BP <140/90 mmHg initially 1
   • For optimal cardiovascular protection, consider a target of 120-129 mmHg systolic 2

3. Long-term follow-up:

   • Regular follow-up every 3 months until BP is controlled, then every 6 months 2
   • Annual monitoring of serum creatinine, eGFR, and potassium for patients on ACE inhibitors/ARBs 2

Treatment Adjustments

If BP remains uncontrolled after initial therapy:

1. Increase to full dose of initial medication 1
2. Add a second agent if BP remains uncontrolled:
   • Thiazide/thiazide-like diuretic if started with ACE inhibitor/ARB 1
   • Consider single-pill combinations to improve adherence 2
3. Add a third agent if needed (typically a calcium channel blocker if not already included)

Important Considerations and Pitfalls

• Avoid therapeutic inertia: Adjust medications within 3 months if target BP is not achieved 2
• Assess medication adherence at each visit
• Monitor for orthostatic hypotension, especially in elderly patients 2
• Watch for contraindications:
  • ACE inhibitors/ARBs are contraindicated in pregnancy 2
  • ACE inhibitors/ARBs can cause hyperkalemia and acute kidney injury 2
• Rule out secondary causes of hypertension if BP is difficult to control

By following this approach, you can effectively manage newly diagnosed hypertension with a BP of 154/90 mmHg, reducing cardiovascular risk and improving patient outcomes.