What is the approach to managing a patient with hypertension?

From the Guidelines

The approach to managing a patient with hypertension should prioritize lifestyle intervention, including weight loss, a Dietary Approaches to Stop Hypertension (DASH)-style eating pattern, moderation of alcohol intake, and increased physical activity, as recommended by the most recent guidelines 1. When managing a patient with hypertension, it is essential to begin with a thorough assessment, including accurate blood pressure measurements, comprehensive medical history, physical examination, and basic laboratory tests.

Key Components of Hypertension Management

• Lifestyle modifications:
  • Weight loss when indicated
  • DASH-style eating pattern, including reducing sodium intake to <2,300 mg/day and increasing potassium intake
  • Moderation of alcohol intake, with no more than 2 servings per day in men and no more than 1 serving per day in women
  • Increased physical activity, with at least 150 minutes of moderate-intensity exercise per week
• Pharmacological therapy:
  • First-line medications may include thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs
  • Consider starting with two medications from different classes for stage 2 hypertension (≥160/100 mmHg)

Considerations for Specific Patient Populations

• African American patients may respond better to thiazides or calcium channel blockers
• Patients with diabetes or chronic kidney disease may prefer ACE inhibitors or ARBs
• Monitor patients every 2-4 weeks until blood pressure is controlled, then every 3-6 months, as recommended by older guidelines 1

Treatment Targets

• Generally, <130/80 mmHg for most patients, though goals may be individualized based on comorbidities and age
• Consider lowering blood pressure even further, to <120/80 mmHg, in certain patient populations, as suggested by older studies 1 It is crucial to prioritize lifestyle intervention and individualize treatment targets based on patient characteristics and comorbidities, as supported by the most recent and highest-quality evidence 1.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake. Many patients will require more than 1 drug to achieve blood pressure goals For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

The approach to managing a patient with hypertension involves:

• Comprehensive cardiovascular risk management
• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake
• Using more than 1 drug to achieve blood pressure goals if necessary, as stated in the aliskiren drug label 2 and 2. It is recommended to follow published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), for specific advice on goals and management.

From the Research

Approach to Managing Hypertension

The approach to managing a patient with hypertension involves a combination of lifestyle modifications and pharmacologic therapy.

• Lifestyle modifications are the foundation of hypertension management and include:
  • Weight loss
  • Healthy dietary pattern with low sodium and high potassium intake
  • Physical activity
  • Moderation or elimination of alcohol consumption
  • Relaxation techniques such as yoga, acupuncture, and mindfulness-based stress reduction programs 3, 4, 5
• Pharmacologic therapy is initiated when lifestyle modifications are not sufficient to control blood pressure.
  • First-line antihypertensive medications include thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers 3, 6, 5, 7
• The decision to initiate antihypertensive medication and the choice of medication should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 3, 5

Blood Pressure Goals

• The goal of blood pressure management is to reduce the risk of cardiovascular disease and mortality.
• The recommended blood pressure goal is less than 130/80 mm Hg for adults under 65 years and less than 130 mm Hg for adults 65 years and older 3
• Reducing blood pressure to less than 140/90 mm Hg is beneficial in reducing the risk of all-cause and cardiovascular mortality in adults with hypertension 6, 5
• Lowering blood pressure to less than 135/85 mm Hg may further reduce the risk of myocardial infarction 5

Monitoring and Evaluation

• Ambulatory and home blood pressure monitoring can improve diagnostic accuracy and should be used in patients with suspected masked or white-coat hypertension 5, 7
• Assessment of adults with hypertension should focus on identifying complications of the condition and comorbid cardiovascular risk factors 5