What is the best approach to manage hypertension (high blood pressure)?

Management of High Blood Pressure

The optimal approach to managing hypertension involves both lifestyle modifications and pharmacological therapy, with a target blood pressure of <140/90 mmHg for the general population and <130/80 mmHg for high-risk patients with diabetes, kidney disease, or established cardiovascular disease. 1

Blood Pressure Classification and Targets

Hypertension is classified as:

• Normal BP: <120/80 mmHg
• Elevated BP: 120-129/<80 mmHg
• Stage 1 Hypertension: 130-139/80-89 mmHg
• Stage 2 Hypertension: ≥140/90 mmHg
• Hypertensive Crisis: >180/120 mmHg 1

Blood pressure targets should be:

• General population: <140/90 mmHg 2, 1
• High-risk patients (diabetes, kidney disease, cardiovascular disease): <130/80 mmHg 2, 1
• Elderly patients: <140/80 mmHg 1

Lifestyle Modifications

Lifestyle modifications are the cornerstone of hypertension management and should be implemented in all patients:

1. Weight management:

   • Maintain normal body weight (BMI 18.5-24.9 kg/m²)
   • Weight loss of just 10 lbs (4.5 kg) can reduce BP by 5-20 mmHg per 10 kg lost 2, 1

2. DASH diet:

   • Rich in fruits, vegetables, and low-fat dairy products
   • Reduced saturated and total fat content
   • Can reduce systolic BP by 8-14 mmHg 2, 1

3. Sodium restriction:

   • Limit to <2.4g sodium (6g sodium chloride) daily
   • Can reduce systolic BP by 2-8 mmHg 2, 1

4. Physical activity:

   • 30 minutes of moderate aerobic activity most days of the week
   • Can reduce systolic BP by 4-9 mmHg 2, 3

5. Alcohol moderation:

   • Men: ≤2 drinks per day
   • Women and lighter-weight persons: ≤1 drink per day
   • Can reduce systolic BP by 2-4 mmHg 2, 1

6. Smoking cessation:

   • Essential for overall cardiovascular risk reduction 2, 1

Pharmacological Treatment

When lifestyle modifications alone are insufficient, medication should be initiated:

First-line Medications:

• ACE inhibitors (e.g., lisinopril) 4
• ARBs (e.g., losartan)
• Calcium channel blockers (e.g., amlodipine) 5
• Thiazide or thiazide-like diuretics 1, 6

Treatment Algorithm:

1. Initial therapy: Start with a single agent at a low dose

   • For non-black patients: ACE inhibitor or ARB
   • For black patients: Calcium channel blocker or thiazide diuretic 1

2. If target BP not achieved:

   • Add a second agent from a different class
   • Most common combination: ACE inhibitor/ARB + calcium channel blocker or diuretic 1

3. If still not at target:

   • Add a third agent (typically a combination of ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1

4. Resistant hypertension:

   • Consider adding spironolactone or eplerenone if not at target on three drugs including a diuretic 1

Special Populations

Diabetes

• Target BP: <130/80 mmHg
• Preferred agents: ACE inhibitors or ARBs 2, 1

Heart Failure

• Target BP: <130/80 mmHg but >120/70 mmHg
• Preferred agents: ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists 1

Elderly Patients

• Start with lower medication doses
• Titrate slowly to avoid orthostatic hypotension
• Check for standing BP drops 1

Pregnancy

• ACE inhibitors and ARBs are contraindicated
• Preferred agents: methyldopa, labetalol, or nifedipine 1

Monitoring and Follow-up

• Follow up every 2-4 weeks until BP goal is achieved
• Then every 3-6 months for ongoing monitoring
• Monitor electrolytes, creatinine, and eGFR, particularly with ACE inhibitors or ARBs
• Home BP monitoring is recommended to improve adherence and control 2, 1

Common Pitfalls to Avoid

1. Inadequate BP measurement: Ensure proper technique with calibrated equipment and patient seated quietly for at least 5 minutes

2. Therapeutic inertia: Don't delay intensification of treatment when targets aren't met

3. Ignoring adherence issues: Assess medication adherence at each visit

4. Overlooking secondary causes: Consider secondary hypertension in resistant cases or young adults (<40 years)

5. Neglecting lifestyle modifications: Continue to emphasize lifestyle changes even after starting medications 7

By implementing this comprehensive approach to hypertension management, cardiovascular risk can be significantly reduced, with clinical trials showing reductions in stroke (35-40%), myocardial infarction (20-25%), and heart failure (50%) 2.