Guidelines for Management of Hypertension with Medications
Hypertension should be managed using a stepped approach with a target blood pressure of <130/80 mmHg for most patients, with individualization for elderly patients based on frailty. 1
Diagnosis and Thresholds for Treatment
- Hypertension is defined as office BP ≥140/90 mmHg, confirmed with office BP, home BP monitoring, or 24-hour ambulatory BP measurements 1
- Drug treatment should be initiated in:
First-Line Pharmacological Treatment
For Non-Black Patients:
- Start with low-dose ACE inhibitor (e.g., lisinopril) or ARB (e.g., losartan)
- Increase to full dose
- Add dihydropyridine calcium channel blocker (e.g., amlodipine)
- Add thiazide/thiazide-like diuretic (e.g., chlorthalidone)
- Add spironolactone or other medications as needed 1
For Black Patients:
- Start with low-dose ARB + dihydropyridine calcium channel blocker OR dihydropyridine calcium channel blocker + thiazide-like diuretic
- Increase to full dose
- Add diuretic or ACE inhibitor/ARB as needed 1
Treatment Targets
- For most patients: ≤140 mmHg systolic and ≤85 mmHg diastolic 2
- For patients with diabetes, renal impairment, or established cardiovascular disease: ≤130/80 mmHg 2, 1
- When using ambulatory or home BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents 2
Special Considerations
Compelling Indications for Specific Medications:
- ACE inhibitors/ARBs: Preferred for patients with diabetes, diabetic nephropathy, or left ventricular hypertrophy 1, 3, 4
- Thiazide diuretics: Effective for most patients, particularly useful in heart failure 5
Important Cautions:
- Do NOT combine ACE inhibitors and ARBs together 1
- For resistant hypertension, consider adding a mineralocorticoid receptor antagonist 1
- Urgent treatment is needed for:
- Accelerated hypertension (severe hypertension with grade III-IV retinopathy)
- Very severe hypertension (>220/120 mmHg)
- Impending complications (TIA, left ventricular failure) 2
Lifestyle Modifications
Lifestyle modifications should be recommended for all patients with hypertension and should complement pharmacological therapy:
- DASH diet (high in fruits, vegetables, low-fat dairy; low in saturated fat) 1
- Sodium restriction to <2,300-2,400 mg/day 1
- Weight loss (5-20 mmHg reduction in SBP per 10 kg lost) 1
- Physical activity: At least 150 minutes/week of moderate-intensity aerobic exercise plus 2-3 resistance training sessions weekly 1, 6
- Moderate alcohol consumption (≤2 standard drinks/day for men, ≤1 for women) 1
- Increased potassium intake through diet 1
Monitoring and Follow-up
- Monitor serum creatinine/eGFR and potassium within 3 months of starting ACE inhibitors, ARBs, or diuretics, then at least annually 1
- Follow-up within 1 month for Stage 1 hypertension with drug therapy and Stage 2 hypertension
- Once BP control is achieved, follow-up every 3-6 months 1
- Adjust medication as needed based on BP response 1
Common Pitfalls to Avoid
- Not considering medication adherence when BP control is not achieved 1
- Using a "one-size-fits-all" approach instead of considering ethnicity, comorbidities, and age 1
- Overlooking secondary causes of hypertension, especially in young patients (<30 years) or those with resistant hypertension 2
- Failing to recognize white coat hypertension (consider ambulatory or home BP monitoring) 2
- Combining ACE inhibitors with ARBs, which increases adverse effects without additional benefit 1
Effective BP control significantly reduces both microvascular and macrovascular complications, with the largest and most consistent benefit being reduction in stroke risk, followed by reductions in myocardial infarction and cardiovascular mortality 3, 4, 7.