What are the recommended treatments for hypertension?

Treatment of High Blood Pressure

The first-line treatment for hypertension includes lifestyle modifications alongside pharmacological therapy with thiazide/thiazide-like diuretics (such as chlorthalidone), calcium channel blockers (CCBs), or ACE inhibitors/ARBs, with medication selection based on patient characteristics and comorbidities. 1, 2

Classification of Blood Pressure

Understanding blood pressure categories is essential for treatment decisions:

Category	Systolic BP	Diastolic BP
Normal BP	<120 mmHg	<80 mmHg
Elevated BP	120-129 mmHg	<80 mmHg
Stage 1 Hypertension	130-139 mmHg	80-89 mmHg
Stage 2 Hypertension	≥140 mmHg	≥90 mmHg

Lifestyle Modifications

All patients with hypertension should implement these evidence-based lifestyle changes:

• Dietary modifications:

  • Reduce sodium intake to <2,300 mg/day
  • Increase consumption of fruits, vegetables, and low-fat dairy products
  • Consider potassium supplementation if appropriate 1, 3

• Physical activity:

  • 90-150 minutes/week of aerobic or dynamic resistance exercise 1
  • Regular exercise has been shown to reduce blood pressure independently 2, 4

• Weight management:

  • Target BMI of 20-25 kg/m²
  • Approximately 1 mmHg systolic BP reduction per 1 kg weight loss 1

• Alcohol limitation:

  • Maximum 2 drinks/day for men and 1 drink/day for women 1, 4

• Smoking cessation 3

• Stress management when appropriate 1, 3

Pharmacological Treatment

First-Line Medications

1. Thiazide/Thiazide-like diuretics:

   • Chlorthalidone 25 mg daily is particularly effective for isolated systolic hypertension
   • Reduces stroke incidence by 36% 1, 5

2. Calcium Channel Blockers (CCBs):

   • Effective first-line therapy, especially for isolated systolic hypertension
   • Reduces stroke incidence by 42% 1

3. ACE inhibitors/ARBs:

   • Indicated for hypertension as monotherapy or in combination
   • Particularly beneficial in patients with diabetes, albuminuria, or heart failure 1, 6

Patient-Specific Considerations

• For Black patients: Initial treatment with a diuretic or CCB, either alone or with a RAS blocker 1
• For patients with diabetes or albuminuria: ACE inhibitors or ARBs as first-line treatment 1
• For elderly patients (>80 years): Target BP of 140-145 mmHg if well tolerated 1
• For adults aged 60+ years: Target systolic BP of 120-129 mmHg if tolerated 1

Effective Combination Therapies

When monotherapy is insufficient, consider these combinations:

• Diuretic + ACE inhibitor
• Diuretic + angiotensin receptor blocker
• Diuretic + calcium channel blocker 1

Target Blood Pressure Goals

• General population: <140 mmHg systolic and close to 130 mmHg if tolerated
• Elderly (>80 years): 140-145 mmHg if well tolerated
• Adults with chronic kidney disease: 120-129 mmHg if eGFR >30 mL/min/1.73m² 1

Important Monitoring Considerations

• Check for orthostatic hypotension, especially in elderly patients
• Regular monitoring of blood pressure, renal function, and electrolytes
• Encourage home blood pressure monitoring
• Consider referral to a hypertension specialist if BP remains elevated despite 6 months of treatment 1

Common Pitfalls to Avoid

• Excessive BP lowering: Reducing systolic BP below 120 mmHg or diastolic below 60 mmHg may increase cardiovascular risk, particularly in patients with coronary artery disease 1
• Medication non-adherence: Continue lifestyle modifications even after starting medications to enhance efficacy and potentially reduce medication requirements 7
• Inadequate follow-up: Regular monitoring is essential to ensure treatment efficacy and detect adverse effects 1
• Neglecting comorbidities: Treatment should account for conditions like diabetes, kidney disease, and heart failure 6, 2