What are the recommended management options for Hypertension (Htn)?

Hypertension Management

The management of hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy with ACE inhibitors/ARBs, calcium channel blockers, or thiazide diuretics as first-line medications when BP targets are not achieved, with most patients requiring at least two medications to reach their goal. 1

Diagnosis and Classification

• Blood pressure should be measured using properly calibrated equipment, with the patient seated and arm at heart level, after 5 minutes of rest, taking at least two measurements per visit 1
• Hypertension classification:
  • Normal BP: <120/80 mmHg
  • Elevated BP (Prehypertension): 120-129/<80 mmHg
  • Stage 1 Hypertension: 130-139/80-89 mmHg
  • Stage 2 Hypertension: ≥140/90 mmHg
  • Hypertensive Crisis: >180/120 mmHg 1

Treatment Targets

• General population: ≤140/90 mmHg
• High-risk patients (diabetes, renal impairment, cardiovascular disease): ≤130/80 mmHg
• Elderly patients (>80 years): Consider initiating treatment only when office SBP ≥160 mmHg 2, 1

Lifestyle Modifications

Lifestyle modifications are the cornerstone for prevention and treatment of hypertension for all patients 2, 1:

1. Dietary approaches:

   • DASH diet or Mediterranean diet (3-11 mmHg reduction)
   • Sodium reduction (3-6 mmHg reduction)
   • Enhanced potassium intake (3-5 mmHg reduction)

2. Physical activity:

   • 150 minutes of moderate aerobic exercise weekly
   • 30-60 minutes of moderate exercise 4-7 days/week (3-8 mmHg reduction)

3. Weight management:

   • Weight loss for overweight/obese patients (1 mmHg reduction per kg lost)

4. Alcohol moderation:

   • Limit to ≤2 drinks daily (maximum 14/week for men, 9/week for women)
   • Can reduce BP by 3-4 mmHg

5. Smoking cessation:

   • Strongly recommended to reduce overall cardiovascular risk 1

Pharmacological Therapy

First-Line Medications

• ACE inhibitors (e.g., lisinopril)
• ARBs (e.g., losartan)
• Calcium channel blockers (e.g., amlodipine)
• Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone) 1, 3

Treatment Algorithm

1. Initial therapy:

   • Start with a single agent at a low dose
   • For non-black patients: Low-dose ACE inhibitor/ARB
   • For black patients: Low-dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 1

2. Combination therapy:

   • Most patients will require at least two antihypertensive medications to achieve target BP 1, 4, 5
   • Consider single-pill combinations to improve adherence

3. Resistant hypertension:

   • Add spironolactone for patients not achieving target BP on three drugs including a diuretic 1, 6
   • Alternatives include amiloride, doxazosin, eplerenone, clonidine, and beta-blockers 6

Special Populations

Diabetes

• Target BP: <130/80 mmHg
• Preferred regimen: RAS inhibitor (ACE inhibitor/ARB) + CCB and/or thiazide-like diuretic 1
• Losartan is specifically indicated for diabetic nephropathy with elevated serum creatinine and proteinuria 4

Heart Failure

• Target BP: <130/80 mmHg but >120/70 mmHg
• Preferred regimen: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1
• Lisinopril is indicated to reduce signs and symptoms of systolic heart failure 5

Left Ventricular Hypertrophy

• Losartan is indicated to reduce stroke risk in patients with hypertension and LVH
• Note: This benefit may not apply to Black patients 4

Elderly Patients

• Start with lower medication doses
• Titrate slowly to avoid orthostatic hypotension
• Lower BP gradually to avoid complications 1

Pregnancy

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

Monitoring and Follow-up

• Monitor every 2-4 weeks until BP goal is achieved, then every 3-6 months
• Routine investigations: urine strip test, blood electrolytes and creatinine, blood glucose, lipid profile, and ECG
• Allow at least four weeks to observe full response to medication changes 1

Common Pitfalls to Avoid

1. Underestimating the importance of lifestyle modifications - These interventions can significantly reduce BP and enhance medication efficacy 2, 1, 7

2. Inadequate dosing or insufficient number of medications - Most patients require at least two medications to reach target BP 1, 4, 5

3. Not considering patient-specific factors - Age, ethnicity, and comorbidities should guide medication selection 1

4. Poor medication adherence - Consider single-pill combinations to improve compliance 6

5. Failure to screen for secondary causes - Particularly important in young adults (<40 years) and resistant hypertension 1, 6