How do I approach elevated hypertension (HTN)?

Management of Elevated Hypertension

For patients with elevated blood pressure (BP >120/80 mmHg), initiate lifestyle modifications immediately, followed by pharmacological therapy with ACE inhibitors/ARBs plus a thiazide diuretic or calcium channel blocker for those with confirmed BP ≥140/90 mmHg. 1

Blood Pressure Classification

• Normal BP: <120/80 mmHg
• Elevated BP (Prehypertension): 120-129/<80 mmHg
• Stage 1 Hypertension: 130-139/80-89 mmHg
• Stage 2 Hypertension: ≥140/90 mmHg
• Hypertensive Crisis: >180/120 mmHg 1

Initial Assessment

1. Confirm elevated BP using standardized measurement techniques:

   • Use validated automated upper arm cuff with appropriate size
   • Patient seated with arm at heart level
   • After 5 minutes of quiet rest
   • Take at least two measurements per visit 1

2. Evaluate for underlying causes and target organ damage:

   • Basic laboratory tests: urine testing for blood and protein, blood electrolytes, creatinine, glucose, lipid panel
   • 12-lead ECG to assess for left ventricular hypertrophy 1
   • Consider secondary causes of hypertension (renovascular disease, endocrine disorders, sleep apnea) 2

Treatment Algorithm

Step 1: Lifestyle Modifications (for all patients with BP >120/80 mmHg)

• DASH diet: can lower systolic BP by 8-14 mmHg 1
• Sodium reduction: <2.4g/day can lower BP by 2-8 mmHg 1
• Weight management: 5-20 mmHg reduction for every 10kg weight loss 1, 3
• Regular physical activity: 3-8 mmHg reduction 1, 4
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1, 5
• Stress management techniques 5

Step 2: Pharmacological Therapy

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

• Initiate drug therapy after 3 months of failed lifestyle modifications if 10-year ASCVD risk ≥10% 1
• Start with a single agent: thiazide diuretic, ACE inhibitor, ARB, or CCB 1

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

• Initiate two-drug combination therapy immediately along with lifestyle modifications 1
• Preferred combinations:
  • ACE inhibitor/ARB + calcium channel blocker
  • ACE inhibitor/ARB + thiazide-like diuretic 1

Step 3: Monitoring and Titration

• Evaluate patients within 1 month of initial diagnosis and treatment initiation
• Monitor BP every 2-4 weeks until goal is achieved, then every 3-6 months 1
• Allow at least 4 weeks to observe full response to medication changes 1
• If BP remains uncontrolled, add a third agent from a different class 2
• Consider resistant hypertension if BP remains elevated despite optimal doses of three different antihypertensive agents including a diuretic 2

Treatment Goals

• General population: <140/90 mmHg 2, 1
• Patients with diabetes or chronic kidney disease: <130/80 mmHg 2, 1
• Lower targets (<130/80 mmHg) may be appropriate for younger patients if achievable without undue treatment burden 2

Special Populations

• African American patients: Consider starting with calcium channel blocker + thiazide diuretic 1
• Elderly patients: Target BP <130/80 mmHg for fit elderly; consider higher targets and more gradual BP reduction in frail elderly 1
• Pregnant patients: Avoid ACE inhibitors and ARBs; prefer calcium channel blockers, beta-blockers, or labetalol 1
• Diabetes patients: Prefer ACE inhibitors or ARBs as first-line therapy 2, 1
• Chronic kidney disease: Prefer ACE inhibitors or ARBs 2, 1

Common Pitfalls to Avoid

1. Clinical inertia: Failing to intensify treatment when BP remains uncontrolled 1
2. Inadequate diuretic therapy: Often needed for effective BP control 1
3. Ignoring medication adherence: Assess at each visit 1
4. Overlooking interfering substances: NSAIDs, stimulants, oral contraceptives can worsen hypertension 1
5. Inappropriate combinations: Avoid combining two RAS blockers (ACE inhibitor + ARB) 1
6. Ignoring white coat effect: Consider home BP monitoring or ambulatory BP monitoring 1

Expected Benefits of Treatment

Treating hypertension significantly reduces:

• Stroke risk by 35-40%
• Heart attack risk by 20-25%
• Heart failure risk by 50% 1
• An SBP reduction of 10 mmHg decreases risk of CVD events by approximately 20-30% 6

By following this structured approach to elevated hypertension management, you can effectively reduce cardiovascular risk and improve patient outcomes through appropriate lifestyle modifications and pharmacological therapy.