What are the initial management recommendations for Hypertension (HTN) according to recent guidelines?

Initial Management Recommendations for Hypertension

According to the most recent guidelines, initial management of hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy with ACE inhibitors or ARBs as first-line agents when diastolic blood pressure remains ≥90 mmHg despite lifestyle changes or is initially ≥100 mmHg. 1

Diagnosis and Classification

Hypertension is diagnosed when:

• Office BP ≥140/90 mmHg (confirmed with repeated measurements)
• Home BP ≥135/85 mmHg
• 24-hour ambulatory BP ≥130/80 mmHg 2, 1

The International Society of Hypertension (ISH) 2020 guidelines classify hypertension as:

• Grade 1: 140-159/90-99 mmHg
• Grade 2: ≥160/100 mmHg 2

Lifestyle Modifications

Lifestyle modifications should be implemented for all patients with hypertension or elevated blood pressure and include:

1. Dietary approaches:

   • DASH diet (rich in fruits, vegetables, low-fat dairy; reduced saturated fats)
   • Sodium restriction to 1200-2300 mg/day
   • Increased potassium intake
   • Expected BP reduction: 3-11 mmHg systolic 1, 3

2. Physical activity:

   • 150 minutes of moderate aerobic exercise weekly
   • 30-60 minutes of moderate activity 4-7 days per week
   • Expected BP reduction: 3-8 mmHg systolic 1, 4

3. Weight management:

   • Target healthy BMI (18.5-24.9 kg/m²)
   • Expected BP reduction: approximately 1 mmHg per kg lost 1

4. Alcohol moderation:

   • ≤14 units/week for men and ≤8 units/week for women
   • Expected BP reduction: 3-4 mmHg systolic 1

5. Smoking cessation 1

Pharmacological Therapy

The 2020 ISH guidelines recommend initiating drug therapy:

1. Immediately in high-risk patients with:

   • Cardiovascular disease
   • Chronic kidney disease
   • Diabetes
   • Target organ damage
   • Age 50-80 years 2

2. After 3-6 months of lifestyle intervention in low-moderate risk patients with persistent BP elevation 2

First-line medication options:

• Non-black patients: Start with low-dose ACE inhibitor/ARB (e.g., lisinopril 10 mg daily or losartan 50 mg daily) 2, 5, 6
• Black patients: Start with low-dose ARB + dihydropyridine calcium channel blocker or dihydropyridine calcium channel blocker + thiazide-like diuretic 2

Medication titration:

1. Start with monotherapy in low-risk grade 1 hypertension and in patients >80 years or frail
2. Increase to full dose if needed
3. Add second agent from a different class if BP remains uncontrolled
4. Add third agent if needed
5. Consider spironolactone or other agents for resistant hypertension 2

Treatment Targets

• General population: <140/90 mmHg 1
• Patients with diabetes or kidney disease: <130/80 mmHg 1
• Older adults (≥65 years): <130 mmHg systolic if tolerated, with diastolic 70-79 mmHg 1

The ISH 2020 guidelines recommend reducing BP by at least 20/10 mmHg, ideally to <140/90 mmHg, with individualization for elderly patients based on frailty 2.

Monitoring and Follow-up

• Check electrolytes, creatinine, and eGFR within 1-2 weeks of initiating ACE inhibitors/ARBs
• Schedule follow-up visits every 2-4 weeks until BP goal is achieved, then every 3-6 months
• Allow at least four weeks to observe full response to medication changes
• Encourage home BP monitoring to guide medication adjustments 1

Special Considerations

• Elderly patients: Start with lower medication doses and titrate slowly to avoid orthostatic hypotension
• Patients with diabetes: ACE inhibitors or ARBs are strongly recommended as first-line agents
• Pregnancy: ACE inhibitors and ARBs are contraindicated; methyldopa, labetalol, or nifedipine are preferred 1

Common Pitfalls to Avoid

1. Inadequate BP measurement technique leading to misdiagnosis
2. Failure to identify white coat or masked hypertension - consider home or ambulatory BP monitoring
3. Underestimating the importance of lifestyle modifications - they can reduce or eliminate the need for medications
4. Inappropriate medication selection for specific populations (e.g., black patients, elderly, pregnant women)
5. Inadequate follow-up after medication initiation or changes

Even when medications are required, lifestyle modifications should be continued as they enhance the efficacy of pharmacologic therapy and may minimize the number and doses of medications required 7, 8.