What are the recommended management strategies for hypertension?

Hypertension Management Strategies

The recommended management for hypertension includes targeting a systolic blood pressure of 120-129 mmHg for most patients through lifestyle modifications and appropriate pharmacological therapy, with first-line medications including thiazide/thiazide-like diuretics, ACE inhibitors/ARBs, and calcium channel blockers. 1

Blood Pressure Targets

• General population: 120-129 mmHg systolic BP 1
• Older patients (≥65 years): 130-139 mmHg systolic BP 1
• Very elderly patients (≥85 years): <140/90 mmHg 1
• High-risk patients (diabetes, CKD, established CVD): <130/80 mmHg 1
• CKD patients with eGFR >30 mL/min/1.73 m²: 120-129 mmHg systolic BP 1
• Post-stroke patients: 120-130 mmHg systolic BP 1

When to Initiate Pharmacological Therapy

Initiate antihypertensive medications when:

• Sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg despite lifestyle modifications 1
• Systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg with:
  • Target organ damage
  • Established cardiovascular disease
  • Diabetes mellitus
  • 10-year cardiovascular disease risk ≥20% 1
• For diabetic patients: Systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg 1

Lifestyle Modifications (First-Line for All Patients)

1. Physical Activity:

   • 30 minutes of moderate aerobic exercise 5-7 days/week
   • Resistance training 2-3 times weekly 1

2. Weight Management:

   • Target BMI: 20-25 kg/m²
   • Target waist circumference: <94 cm (men), <80 cm (women) 1

3. Dietary Modifications:

   • Salt restriction: 5-6 g per day
   • Increase consumption of vegetables, fruits, fish, nuts, unsaturated fatty acids
   • Reduce consumption of red meat
   • Low-fat dairy products 1

4. Alcohol Limitation:

   • Men: <14 units/week
   • Women: <8 units/week 1

5. Smoking Cessation 1

Pharmacological Therapy

First-Line Medications

1. Thiazide or thiazide-like diuretics 1, 2
2. ACE inhibitors (e.g., lisinopril) or ARBs 1, 3, 2
3. Calcium channel blockers (e.g., amlodipine) 1, 4, 2

Patient-Specific Considerations

• Black patients: Initial therapy should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 1
• Diabetes with proteinuria: RAS blockers (ACE inhibitors or ARBs) are recommended 1
• Heart failure with reduced ejection fraction: Combination of ACE inhibitor/ARB, beta-blocker, diuretic, MRA, and SGLT2 inhibitors 1
• Heart failure with preserved ejection fraction: SGLT2 inhibitors 1

Combination Therapy

• Initial combination therapy with two drugs at low doses for patients with BP ≥160/100 mmHg or high CV risk 1
• Triple therapy (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) if BP remains uncontrolled 1
• For resistant hypertension, consider adding a fourth agent or specialist referral 1

Monitoring and Follow-Up

• Regular follow-up appointments (typically monthly until target BP is achieved) 1
• Home blood pressure monitoring to detect white coat hypertension and monitor treatment effectiveness 1
• Consider ambulatory blood pressure monitoring when clinic readings show unusual variability 1
• Evaluate for secondary causes of hypertension when there is:
  • Sudden onset or worsening of hypertension
  • Resistance to multidrug regimen
  • Young age
  • Presence of clinical clues 1

Additional Cardiovascular Risk Reduction

• Aspirin: 75 mg daily for secondary prevention and primary prevention in patients >50 years with controlled BP (<150/90 mmHg) and 10-year CVD risk ≥20% 1
• Statins: Recommended for all patients with hypertension complicated by cardiovascular disease and for primary prevention in those with 10-year CVD risk ≥20% 1

Improving Medication Adherence

• Simplify regimens when possible (once-daily dosing or fixed-dose combinations) 1
• Consider cultural, social, and economic factors that may influence adherence 1
• Implement effective behavioral and motivational strategies 1

Common Pitfalls to Avoid

• Failing to recognize white coat hypertension or masked hypertension
• Not considering secondary causes in resistant hypertension
• Inadequate attention to lifestyle modifications
• Not individualizing BP targets based on age and comorbidities
• Failing to simplify medication regimens to improve adherence

Hypertension management requires a comprehensive approach that combines appropriate lifestyle modifications with pharmacological therapy tailored to the individual patient's characteristics and comorbidities. Regular monitoring and follow-up are essential to ensure optimal blood pressure control and reduce cardiovascular risk.