What are the guidelines for managing hypertension?

Guidelines for Managing Hypertension

The current standard for hypertension management recommends combination therapy with a renin-angiotensin system blocker (ACE inhibitor or ARB) plus a calcium channel blocker or thiazide/thiazide-like diuretic as initial treatment for most patients with hypertension (≥140/90 mmHg). 1

Diagnosis and Classification

• Definition: Hypertension is defined as persistent blood pressure ≥140/90 mmHg

• Classification:

  • Normal BP: <120/70 mmHg
  • Elevated BP: 120-139/70-89 mmHg
  • Hypertension: ≥140/90 mmHg

• Measurement: Out-of-office BP measurements are strongly recommended to confirm diagnosis, using standardized techniques with properly calibrated equipment

Treatment Approach

When to Start Treatment

1. Immediate treatment for patients with:

   • Confirmed hypertension (≥140/90 mmHg)
   • Elevated BP (120-139/70-89 mmHg) with high-risk conditions:
     • Established cardiovascular disease
     • Diabetes mellitus
     • Chronic kidney disease
     • Family history of premature CVD
     • Evidence of hypertension-mediated organ damage

2. Lifestyle modifications only for patients with:

   • Elevated BP (120-139/70-89 mmHg) with low cardiovascular risk (<10% 10-year risk)

Target Blood Pressure

• General population: <140/90 mmHg
• High-risk patients (diabetes, kidney disease, established CVD): <130/80 mmHg
• Elderly patients (>65 years): <140/90 mmHg (with careful monitoring for orthostatic hypotension)

Pharmacological Treatment

First-Line Therapy

For most patients with hypertension (≥140/90 mmHg), initiate with combination therapy:

• Preferred combinations:

  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker (CCB)
  • RAS blocker (ACE inhibitor or ARB) + thiazide/thiazide-like diuretic

• Use single-pill combinations whenever possible to improve adherence 1

Step-by-Step Algorithm

1. Initial therapy: Two-drug combination (RAS blocker + CCB or diuretic)

2. If BP not controlled: Increase to three-drug combination

   • RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic
   • Preferably as a single-pill combination

3. If BP still not controlled: Add spironolactone (25-50 mg daily)

4. If spironolactone not tolerated or contraindicated:

   • Consider eplerenone OR
   • Add beta-blocker OR
   • Add alpha-blocker OR
   • Add centrally acting agent

Important Cautions

• Never combine two RAS blockers (ACE inhibitor + ARB) - this is contraindicated 1
• Monitor electrolytes, creatinine, and eGFR when using ACE inhibitors, ARBs, or spironolactone
• Check for orthostatic hypotension in elderly patients and those with diabetes

Lifestyle Modifications

Lifestyle interventions should be implemented concurrently with pharmacological therapy:

• Salt restriction: 5-6g per day (reduces SBP by 3-6 mmHg)
• Physical activity: 30 minutes of moderate aerobic exercise 5-7 days/week (reduces SBP by 3-8 mmHg)
• Weight reduction: Target BMI of 25 kg/m² (1 mmHg reduction per kg lost)
• Alcohol moderation: ≤20-30g ethanol/day for men, ≤10-20g for women
• Increased consumption: Vegetables, fruits, low-fat dairy products
• Smoking cessation: Offer assistance to all smokers 1

Special Populations

Diabetes

• Target BP: <130/80 mmHg
• Preferred agents: RAS blocker + CCB and/or thiazide-like diuretic
• Monitor for orthostatic hypotension

Chronic Kidney Disease

• Target BP: <130/80 mmHg
• Preferred agents: RAS blocker-based regimen

Elderly Patients

• Start with lower doses and titrate slowly
• Monitor for orthostatic hypotension
• For patients ≥85 years, consider less aggressive targets

Black Patients

• May respond better to CCBs and diuretics than to RAS blockers as monotherapy
• Consider combination of CCB + thiazide-like diuretic if RAS blocker not indicated

Follow-up and Monitoring

• Follow-up every 2-4 weeks until BP goal is achieved
• Once controlled, monitor every 3-6 months
• Assess medication adherence and side effects at each visit
• Monitor electrolytes, creatinine, and eGFR, particularly with RAS blockers and diuretics
• Allow at least 4 weeks to observe full response to medication changes

Common Pitfalls to Avoid

1. Inadequate initial therapy: Starting with monotherapy when combination therapy is indicated
2. White coat hypertension: Failing to confirm office readings with home or ambulatory monitoring
3. Therapeutic inertia: Not intensifying treatment when targets aren't met
4. Medication non-adherence: Not addressing adherence issues or using complex regimens
5. Ignoring secondary causes: Not investigating resistant hypertension for underlying causes
6. Inappropriate combinations: Combining two RAS blockers

By following these evidence-based guidelines, clinicians can effectively manage hypertension and reduce the risk of cardiovascular events, stroke, and mortality in their patients.