What is the guideline treatment for hypertension?

Guideline Treatment for Hypertension

The management of hypertension requires a combination of lifestyle modifications and pharmacological therapy to achieve a blood pressure target of <130/80 mmHg for most adults, with medication selection based on patient characteristics including age, race, and comorbidities. 1

Diagnosis and Assessment

• Hypertension is defined as persistent BP ≥140/90 mmHg in office measurements or ≥135/85 mmHg in home BP monitoring 2
• Use validated automated devices with appropriate cuff size
• Confirm diagnosis with multiple readings across different visits or with home/ambulatory BP monitoring
• Initial evaluation should include assessment of:
  • Cardiovascular risk factors
  • Target organ damage
  • Comorbid conditions that may influence treatment selection

Lifestyle Modifications (First-line for all patients)

Lifestyle modifications can reduce systolic BP significantly and should be implemented for all patients:

• Weight loss: 5-20 mmHg reduction per 10 kg lost 1
• DASH diet: 8-14 mmHg reduction 1
• Sodium restriction (<2.3g/day): 2-8 mmHg reduction 1
• Physical activity (150 min/week moderate activity): 4-9 mmHg reduction 1
• Moderate alcohol consumption: 2-4 mmHg reduction 1

Pharmacological Treatment

When to Initiate Drug Therapy

• Immediate initiation for BP ≥160/100 mmHg (Grade 2 hypertension) 2
• For BP 140-159/90-99 mmHg (Grade 1 hypertension):
  • Immediate initiation for high-risk patients (with CVD, CKD, diabetes, organ damage, or aged 50-80 years)
  • After 3-6 months of lifestyle intervention if BP remains elevated in low-risk patients 2

First-line Medications

1. Non-Black Patients:

   • ACE inhibitor or ARB
   • Calcium channel blocker (CCB)
   • Thiazide or thiazide-like diuretic 1

2. Black Patients:

   • Calcium channel blocker
   • Thiazide or thiazide-like diuretic 1

3. Patients with Specific Comorbidities:

   • Diabetes or CKD: ACE inhibitor or ARB preferred 1
   • Heart failure: ACE inhibitor/ARB, beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor 1

Treatment Algorithm

1. Initial therapy:

   • Start with low dose of preferred agent based on patient characteristics
   • Consider monotherapy in low-risk grade 1 hypertension and in frail elderly patients
   • Consider dual therapy for grade 2 hypertension (≥160/100 mmHg) 2

2. Titration:

   • Increase to full dose if BP not at target
   • If BP still not controlled after 2-4 weeks, add second agent from a different class 1

3. Triple therapy:

   • If BP remains uncontrolled, use combination of ACE/ARB + CCB + thiazide/thiazide-like diuretic 1

4. Resistant hypertension:

   • Add spironolactone (25-50 mg/day) if potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m²
   • Alternative fourth-line agents: amiloride, doxazosin, eplerenone, clonidine, or beta-blockers 1

Blood Pressure Targets

• General adult population: <130/80 mmHg 1
• Elderly patients (≥65 years): 130-140/80 mmHg if tolerated 1
• Patients with diabetes or CKD: <130/80 mmHg 1
• Minimum goal: Reduce BP by at least 20/10 mmHg 2

Monitoring and Follow-up

• Schedule follow-up based on BP level:

  • BP 130-139/80-89 mmHg: within 1 month
  • BP 140-159/90-99 mmHg: within 2-4 weeks
  • BP ≥160/100 mmHg: within 1-2 weeks 1

• Monitor laboratory parameters:

  • Check serum creatinine, eGFR, and potassium within 2-4 weeks of starting ACE inhibitors, ARBs, or diuretics 1
  • Aim to achieve BP control within 3 months 1

Special Considerations

• Elderly patients: Start with lower doses and titrate more gradually
• Pregnancy: Avoid ACE inhibitors and ARBs
• Medication adherence: Consider once-daily dosing and single-pill combinations to improve compliance 2

Common Pitfalls to Avoid

• Inadequate dosing or insufficient combination therapy
• Failure to address lifestyle modifications
• Not accounting for white coat hypertension (use home BP monitoring)
• Inappropriate medication selection based on comorbidities
• Discontinuing medications when BP normalizes
• Not considering secondary causes of hypertension in resistant cases

The most recent guidelines emphasize the importance of early intervention, appropriate medication selection based on patient characteristics, and achieving target BP within 3 months to reduce cardiovascular risk.