What is the best treatment approach for a patient with hypertension?

Treatment Approach for Hypertension with Blood Pressure 170/90

For a patient with blood pressure of 170/90 mmHg, immediate initiation of a two-drug combination therapy is recommended, preferably including a thiazide-type diuretic plus an ACE inhibitor, ARB, or calcium channel blocker. 1

Classification and Risk Assessment

This blood pressure reading of 170/90 mmHg falls into Stage 2 Hypertension according to current guidelines:

• Stage 2 Hypertension is defined as ≥140/90 mmHg 1
• This level of hypertension significantly increases cardiovascular risk and requires prompt intervention

Initial Treatment Approach

Pharmacological Therapy

1. Two-drug combination therapy is indicated:

   • First-line options include:
     • Thiazide/thiazide-like diuretic (e.g., hydrochlorothiazide, chlorthalidone) PLUS
     • Either an ACE inhibitor (e.g., lisinopril), ARB (e.g., losartan), or calcium channel blocker (e.g., amlodipine) 1, 2

2. Rationale for combination therapy:

   • Blood pressure is >20/10 mmHg above goal (<130/80 mmHg)
   • Combination therapy achieves faster and more effective BP control
   • Different mechanisms of action provide complementary effects 1

Drug Selection Considerations

• ACE inhibitors like lisinopril are indicated for hypertension and have shown benefits in reducing cardiovascular morbidity and mortality 3
• ARBs like losartan are effective alternatives, especially for patients who cannot tolerate ACE inhibitors 4
• Calcium channel blockers are particularly effective for isolated systolic hypertension 1
• Thiazide diuretics remain cornerstone therapy with proven mortality benefits 2

Target Blood Pressure Goals

• Primary target: <130/80 mmHg for most adults under 65 years 1
• For elderly patients (>65 years): Target systolic BP of 130-139 mmHg if tolerated 1
• For very elderly patients (>80 years): Target of 140-145 mmHg is acceptable if well tolerated 1

Lifestyle Modifications

Alongside pharmacological therapy, implement these essential lifestyle changes:

• Dietary changes:
  • Reduce sodium intake to <2,300 mg/day
  • Increase fruits, vegetables, and low-fat dairy products
  • Follow DASH diet pattern 1
• Physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise 1
• Weight management: Target BMI of 20-25 kg/m² (approximately 1 mmHg SBP reduction per 1 kg weight loss) 1
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women 1

Monitoring and Follow-up

• Initial follow-up: Monitor BP monthly until control is achieved 1
• Laboratory monitoring: Check renal function and electrolytes 2-4 weeks after initiating therapy
• Home BP monitoring: Encourage patient to monitor BP at home to guide treatment adjustments 1
• Medication adjustments: If BP remains elevated after 2-4 weeks, increase doses or add additional agents

Special Considerations

• Diabetes: ACE inhibitors or ARBs are preferred first-line agents 1
• Chronic kidney disease: Consider loop diuretics instead of thiazides if eGFR <30 mL/min 1
• Heart failure: Include beta-blockers and consider aldosterone antagonists 1
• Black patients: Initial treatment with a diuretic or calcium channel blocker may be more effective 1

Treatment Resistance

If BP remains elevated despite adherence to a three-drug regimen including a diuretic:

• Consider adding an aldosterone antagonist as fourth-line therapy
• Evaluate for secondary causes of hypertension
• Consider referral to a hypertension specialist if BP remains uncontrolled after 6 months 1

Remember that early and aggressive treatment of hypertension at 170/90 mmHg is critical to reduce the risk of cardiovascular events, stroke, and mortality.