What are the initial management and treatment options for hypertension?

Initial Management and Treatment Options for Hypertension

The initial management of hypertension should include lifestyle modifications for all patients, followed by pharmacological therapy with a thiazide-like diuretic, ACE inhibitor/ARB, or calcium channel blocker for patients with BP ≥140/90 mmHg, with combination therapy recommended for those with BP ≥160/100 mmHg. 1, 2

Diagnosis and Classification

Hypertension is defined as office BP ≥140/90 mmHg, which can be confirmed with:

• Home BP monitoring (≥135/85 mmHg)
• 24-hour ambulatory BP monitoring (≥130/80 mmHg) 2

Blood pressure classification according to the American College of Cardiology 2:

Category	Systolic BP	Diastolic BP
Normal BP	<120 mmHg	<80 mmHg
Elevated BP	120-129 mmHg	<80 mmHg
Stage 1 Hypertension	130-139 mmHg	80-89 mmHg
Stage 2 Hypertension	≥140 mmHg	≥90 mmHg

First-Line Management: Lifestyle Modifications

Lifestyle modifications should be implemented for all patients with hypertension or elevated BP 1:

1. Dietary modifications:

   • DASH diet (rich in fruits, vegetables, low-fat dairy)
   • Sodium restriction (<5g salt/day or 2g sodium)
   • Increased potassium intake
   • Limited alcohol consumption (≤14 units/week for men, ≤8 units/week for women)

2. Physical activity:

   • 150 minutes of moderate-intensity aerobic activity per week
   • Dynamic or isometric resistance training 2-3 times/week

3. Weight management:

   • Target healthy BMI (20-25 kg/m²)
   • Healthy waist circumference (<102 cm in men, <88 cm in women)

4. Smoking cessation if applicable

Pharmacological Management

Initial Drug Selection

For patients with BP ≥140/90 mmHg, pharmacological therapy should be initiated 1, 2:

1. First-line options (any of these can be used initially):

   • ACE inhibitors (e.g., lisinopril)
   • ARBs
   • Thiazide-like diuretics (preferably chlorthalidone or indapamide)
   • Dihydropyridine calcium channel blockers (e.g., amlodipine)

2. Special considerations:

   • For patients with albuminuria or coronary artery disease: ACE inhibitor or ARB preferred 1
   • For Black patients: Calcium channel blocker or thiazide diuretic preferred 1

Combination Therapy

For patients with BP ≥160/100 mmHg, initial therapy with two drugs is recommended 1:

• Optimal two-drug combination: RAS blocker (ACE inhibitor or ARB) + calcium channel blocker or thiazide-like diuretic
• Avoid combining ACE inhibitors with ARBs or renin inhibitors as this is potentially harmful 1

Treatment Algorithm

1. Step 1: Start with one agent from first-line options for BP 140-159/90-99 mmHg
2. Step 2: If BP not controlled, add a second agent from a different class
3. Step 3: If BP still not controlled, use a three-drug combination (RAS blocker + calcium channel blocker + thiazide-like diuretic)
4. Step 4: For resistant hypertension, add spironolactone (mineralocorticoid receptor antagonist) 1

Blood Pressure Targets

The recommended BP targets are 1, 2:

• General adult population: <140/90 mmHg initially, then target 120-129/<80 mmHg if tolerated
• Older adults (≥65 years): Systolic BP 130-139 mmHg
• Very elderly (≥85 years) or frail patients: Consider more lenient targets (<140/90 mmHg)
• Patients with diabetes or chronic kidney disease: Target systolic BP 130-139 mmHg

Monitoring and Follow-up

• Monitor BP every 1-3 months until target is achieved
• Check electrolytes and renal function after starting ACE inhibitors, ARBs, or diuretics
• Once controlled, follow up yearly for BP and cardiovascular risk assessment 2

Common Pitfalls to Avoid

1. Therapeutic inertia: Failure to intensify treatment when BP remains above target
2. Inappropriate drug combinations: Combining drugs with similar mechanisms (e.g., ACE inhibitor + ARB)
3. Inadequate dosing: Not titrating medications to effective doses
4. Overlooking secondary causes: Not investigating resistant hypertension
5. Neglecting lifestyle modifications: Focusing solely on pharmacological therapy

By following this evidence-based approach to hypertension management, clinicians can effectively reduce cardiovascular morbidity and mortality in their patients.