What is the initial treatment protocol for patients with hypertension?

Initial Treatment Protocol for Hypertension

The initial treatment protocol for hypertension should include lifestyle modifications for all patients, with immediate pharmacological therapy for those with blood pressure ≥160/100 mmHg or high-risk patients with BP ≥140/90 mmHg, starting with a low-dose ACE inhibitor or ARB for non-Black patients and an ARB plus dihydropyridine calcium channel blocker or thiazide-like diuretic for Black patients. 1, 2

Diagnosis Confirmation

• Hypertension is diagnosed when:
  • Office BP ≥140/90 mmHg
  • Home BP ≥135/85 mmHg
  • 24-hour ambulatory BP ≥130/80 mmHg 2
• Use validated automated upper arm cuff device with appropriate cuff size
• Measure BP in both arms at first visit; use arm with higher reading for subsequent measurements
• Take 2-3 readings, 1 minute apart, after patient sits quietly for 5 minutes 2

Initial Treatment Approach Based on BP Level

For BP 140-159/90-99 mmHg (Grade 1 Hypertension):

1. Start lifestyle modifications for all patients
2. Start immediate drug therapy for:
   • High-risk patients (with CVD, CKD, diabetes, organ damage, or aged 50-80 years)
   • For low-risk patients: Try lifestyle modifications for 3-6 months; start medications if BP remains elevated 1, 2

For BP ≥160/100 mmHg (Grade 2 Hypertension):

1. Start lifestyle modifications
2. Start drug therapy immediately 1

Lifestyle Modifications (For All Patients)

• Weight loss for overweight patients (5-20 mmHg reduction per 10 kg lost)
• DASH diet (8-14 mmHg reduction): rich in fruits, vegetables, whole grains, low-fat dairy
• Sodium restriction to <2,300 mg/day (2-8 mmHg reduction)
• Increased physical activity: 150 minutes/week of moderate-intensity activity (4-9 mmHg reduction)
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women (2-4 mmHg reduction) 1, 2

Initial Pharmacological Therapy

For Non-Black Patients:

• Start with low-dose ACE inhibitor or ARB (e.g., lisinopril 10 mg daily) 1, 3
• If BP not controlled, increase to full dose
• If still not controlled, add thiazide/thiazide-like diuretic 1

For Black Patients:

• Start with low-dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide/thiazide-like diuretic
• If BP not controlled, increase to full dose
• If still not controlled, add diuretic or ACE inhibitor/ARB 1

Special Considerations:

• For patients with albuminuria (UACR ≥30 mg/g): Start with ACE inhibitor or ARB 1
• For patients with established coronary artery disease: ACE inhibitors or ARBs are first-line 1
• For patients with diabetes: ACE inhibitor or ARB is recommended as foundation of treatment 2
• Consider monotherapy only in low-risk grade 1 hypertension or in patients >80 years or frail 1, 2

Treatment Targets and Monitoring

• Target BP: <130/80 mmHg for most adults 2
• Aim to reduce BP by at least 20/10 mmHg 1
• Monitor BP control and aim to achieve target within 3 months 1
• For patients on ACE inhibitors, ARBs, or diuretics:
  • Monitor serum creatinine, eGFR, and potassium within 2-4 weeks of starting therapy
  • Continue monitoring at least annually 1, 2

Common Pitfalls to Avoid

1. Delayed treatment initiation: Don't delay pharmacotherapy in high-risk patients or those with BP ≥160/100 mmHg
2. Inappropriate combinations: Never combine ACE inhibitors with ARBs or direct renin inhibitors due to increased risk of hyperkalemia, syncope, and acute kidney injury 1
3. Inadequate follow-up: Schedule follow-up within 2-4 weeks for patients with BP 140-159/90-99 mmHg and within 1-2 weeks for patients with BP ≥160/100 mmHg 2
4. Ignoring race-based differences: Treatment protocols differ between Black and non-Black patients due to differences in response to certain medications 1
5. Insufficient lifestyle counseling: Lifestyle modifications are essential components of treatment and enhance the effectiveness of medications 4

By following this structured approach to hypertension management, clinicians can effectively reduce cardiovascular morbidity and mortality in patients with hypertension.