What are the recommended treatments for hypertension?

Recommended Treatments for Hypertension

The recommended first-line treatment for hypertension includes both lifestyle modifications and pharmacological therapy with ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics, or dihydropyridine calcium channel blockers, with specific medication choices based on patient characteristics and comorbidities. 1

Lifestyle Modifications

Lifestyle modifications are essential for all patients with hypertension and should be implemented alongside pharmacological therapy:

• Weight management: Achieve and maintain healthy body mass index (20-25 kg/m²); approximately 1 mmHg SBP reduction per 1 kg weight loss 2
• Dietary modifications:
  • Reduce sodium intake (<2,300 mg/day) 1
  • Increase consumption of fruits and vegetables (8-10 servings/day) 1
  • Increase low-fat dairy products (2-3 servings/day) 1
  • Increase potassium intake through diet 2
• Physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise 2
• Alcohol limitation: No more than 2 servings/day for men and 1 serving/day for women 1

Pharmacological Therapy

First-Line Medications

• ACE inhibitors (e.g., enalapril)
• Angiotensin receptor blockers (e.g., candesartan)
• Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide)
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 3

Treatment Algorithm

1. For BP ≥140/90 mmHg: Initiate lifestyle therapy plus prompt pharmacological treatment 1
2. For BP ≥160/100 mmHg: Initiate lifestyle therapy plus prompt initiation of two drugs or a single-pill combination 1
3. For specific populations:
   • Patients with diabetes or albuminuria: ACE inhibitor or ARB as first-line 1
   • Black patients: Initial treatment should include a diuretic or CCB, either alone or with a RAS blocker 1
   • Heart failure patients: Treatment should include ACE inhibitor/ARB, beta-blocker, and diuretic/MRA 1

Blood Pressure Targets

• General adult population: <140/90 mmHg 2
• High-risk patients (diabetes, CKD, CVD): <130/80 mmHg 2
• Adults aged 60+ years: Target SBP of 120-129 mmHg if tolerated 1
• Elderly patients (>80 years): Target SBP of 140-145 mmHg if well tolerated 2
• Patients with CKD: Target SBP of 120-129 mmHg if eGFR >30 mL/min/1.73m² 1
• Stroke patients: Target SBP of 120-130 mmHg 1

Management of Resistant Hypertension

Resistant hypertension is defined as BP ≥130/80 mmHg despite adherence to ≥3 antihypertensive medications at optimal doses, including a diuretic 2.

Treatment approach:

1. Reinforce lifestyle measures, especially sodium restriction
2. Add low-dose spironolactone to existing treatment
3. If spironolactone is not tolerated, consider:
   • Eplerenone
   • Higher dose thiazide/thiazide-like diuretic
   • Loop diuretic
   • Addition of bisoprolol or doxazosin 1, 2

Monitoring and Follow-up

• Regular monitoring of blood pressure, renal function, and electrolytes
• For patients treated with ACE inhibitors, ARBs, or diuretics: Monitor serum creatinine/eGFR and potassium at least annually 1
• Home blood pressure monitoring is encouraged to guide treatment adjustments 2

Common Pitfalls and Caveats

• Avoid combination of ACE inhibitors and ARBs or combinations with direct renin inhibitors 1
• Medication dosing: Start with lower doses in elderly patients (e.g., amlodipine 2.5 mg) 2
• Drug interactions: Be aware of potential interactions, particularly with CYP3A4 inhibitors and amlodipine 2
• Comorbidities:
  • Avoid non-dihydropyridine calcium channel blockers in heart failure patients 2
  • Beta-blockers may mask hypoglycemia symptoms in diabetic patients 2
  • Monitor for hyperkalemia when using spironolactone with ACE inhibitors or ARBs 1

By following these evidence-based recommendations and tailoring treatment to individual patient characteristics and comorbidities, hypertension can be effectively managed to reduce cardiovascular morbidity and mortality.