What are the management steps for hypertension?

Management Steps for Hypertension

For patients with hypertension, implement lifestyle modifications for all cases, and initiate antihypertensive medication for those with sustained systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg, with a target of <130/80 mmHg for optimal cardiovascular risk reduction. 1

Blood Pressure Classification

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

Proper Blood Pressure Measurement

• Use a validated, properly calibrated device
• Patient should be seated with arm supported at heart level
• Use appropriate cuff size for arm circumference
• Take at least two measurements, 1-2 minutes apart
• Avoid talking during measurement
• Read to nearest 2 mmHg
• Record diastolic as disappearance of sounds (phase V)
• Consider ambulatory or home BP monitoring for:
  • Unusual BP variability
  • Possible white coat hypertension
  • Resistant hypertension
  • Symptomatic hypotension 2

Initial Evaluation

All hypertensive patients should undergo:

• Urine strip test for protein and blood
• Serum creatinine and electrolytes
• Blood glucose (fasting preferred)
• Blood lipid profile
• Electrocardiogram
• Cardiovascular risk assessment 2, 1

Treatment Algorithm

Step 1: Lifestyle Modifications (for all patients)

• Sodium restriction (<1500 mg/day)
• DASH diet rich in fruits, vegetables, whole grains, low-fat dairy
• Physical activity (90-150 minutes/week)
• Weight management (1 mmHg SBP reduction per 1 kg weight loss)
• Alcohol moderation
• Smoking cessation 1, 3

Step 2: Pharmacological Treatment

For Stage 1 Hypertension (130-139/80-89 mmHg):

• Start medications if patient has:
  • Clinical cardiovascular disease
  • Diabetes mellitus
  • Chronic kidney disease
  • 10-year cardiovascular disease risk ≥10% 1

For Stage 2 Hypertension (≥140/90 mmHg):

• Start medications along with lifestyle modifications
• For BP ≥160/100 mmHg, consider initiating with two antihypertensive medications 1, 3

First-line medication options:

• Thiazide or thiazide-like diuretics
• ACE inhibitors or ARBs
• Calcium channel blockers 1, 3

Special populations:

• Diabetes/CKD: Include ACE inhibitor or ARB
• African descent: Thiazide-like diuretic plus CCB is particularly effective
• Elderly (≥65 years): Target diastolic BP <80 mmHg with systolic 130-139 mmHg
• Pregnancy: Avoid ACE inhibitors/ARBs; use methyldopa, labetalol, or nifedipine 1

Monitoring and Follow-up

• Monitor BP response, renal function, and electrolytes within 2-4 weeks of starting or adjusting medications
• Encourage home BP monitoring to guide treatment adjustments
• Schedule follow-up within 2-4 weeks after adding new medications 1

Hypertensive Crisis Management

For severe hypertension (SBP >180 mmHg or DBP >120 mmHg):

Hypertensive Emergency (with acute end-organ damage):

• Admit to intensive care unit
• Immediate BP reduction with short-acting IV antihypertensives (labetalol, esmolol, fenoldopam, nicardipine)
• Avoid hydralazine, immediate-release nifedipine 4

Hypertensive Urgency (severe hypertension without acute end-organ damage):

• May be treated with oral antihypertensives as outpatient
• Close follow-up within days 4

Common Pitfalls to Avoid

1. Failing to confirm elevated BP readings before diagnosing hypertension (average of ≥2 readings on ≥2 occasions)
2. Overlooking secondary causes of hypertension in resistant cases
3. Inadequate dosing or insufficient combination therapy
4. Not accounting for white coat hypertension (use home or ambulatory monitoring)
5. Poor adherence monitoring
6. Ignoring lifestyle modifications as foundation of treatment 1, 5

By following these evidence-based steps, hypertension can be effectively managed to reduce cardiovascular morbidity and mortality. An SBP reduction of 10 mmHg decreases risk of cardiovascular events by approximately 20-30% 3.