What is the recommended treatment for stage 2 hypertension?

Treatment of Stage 2 Hypertension

For stage 2 hypertension (≥140/90 mmHg), treatment should include both lifestyle modifications and initiation of a two-drug combination therapy with agents from different classes. 1

Initial Pharmacological Management

First-Line Therapy

• Initiate with a combination of two antihypertensive medications from different classes:
  • ACE inhibitor or ARB + calcium channel blocker (preferred combination)
  • ACE inhibitor or ARB + thiazide-like diuretic 2, 1

Medication Selection Considerations

• First-line drug classes include:

  • Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide)
  • ACE inhibitors (e.g., enalapril)
  • ARBs (e.g., losartan)
  • Calcium channel blockers (e.g., amlodipine) 3, 2

• For African American patients, consider starting with a calcium channel blocker + thiazide diuretic combination 1

• Avoid simultaneous use of ACE inhibitor + ARB + renin inhibitor as this combination is potentially harmful 1

Follow-Up and Monitoring

• Evaluate within 1 month of initial diagnosis and treatment initiation 1
• Monitor BP every 2-4 weeks until goal is achieved, then every 3-6 months 2
• Allow at least 4 weeks to observe full response to medication changes 2
• Target BP goal for most adults: <130/80 mmHg 2, 3

Escalation of Therapy

If BP remains uncontrolled:

1. Triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic 2
2. Fourth-line agent: Add spironolactone if BP remains uncontrolled on optimized triple therapy 2
   • Alternatives if spironolactone is contraindicated: amiloride, eplerenone, doxazosin, clonidine, or beta-blocker 2

Essential Lifestyle Modifications

All patients with stage 2 hypertension should implement the following lifestyle changes alongside medication therapy:

• DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy (3-11 mmHg reduction) 2
• Sodium reduction: Limit to <2300 mg/day (3-6 mmHg reduction) 2
• Physical activity: 150 minutes/week of moderate-intensity aerobic activity (3-8 mmHg reduction) 2
• Weight management: Target BMI <25 kg/m² (1 mmHg reduction per kg lost) 2
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women (3-4 mmHg reduction) 2, 4
• Increased potassium intake: Through fruits and vegetables (3-5 mmHg reduction) 2

Special Considerations

• Elderly patients: Start with lower medication doses and titrate more slowly; target same BP goals for fit elderly patients 2
• Pregnancy: Avoid ACE inhibitors and ARBs; prefer calcium channel blockers, beta-blockers, or labetalol 2
• Diabetes or CKD: Target BP <130/80 mmHg; prefer ACE inhibitors or ARBs 2
• Hypertensive crisis (>180/120 mmHg): Requires immediate evaluation and prompt treatment 5

Common Pitfalls to Avoid

• Clinical inertia (failing to intensify therapy when BP remains uncontrolled)
• Inadequate diuretic therapy
• Ignoring medication adherence issues
• Overlooking interfering substances (NSAIDs, stimulants, oral contraceptives)
• Inappropriate medication combinations (e.g., combining two RAS blockers) 2
• Using immediate-release nifedipine or hydralazine for urgent BP control 5

Remember that successful treatment of hypertension significantly reduces cardiovascular morbidity and mortality. An SBP reduction of 10 mmHg decreases risk of cardiovascular events by approximately 20-30% 3.