What is the initial treatment approach for patients with hypertension?

Initial Treatment Approach for Hypertension

For patients with newly diagnosed hypertension, the initial treatment should include lifestyle modifications for all patients, with immediate drug therapy for those with Grade 2 hypertension (≥160/100 mmHg) or Grade 1 hypertension (140-159/90-99 mmHg) with high cardiovascular risk. 1

Diagnosis and Assessment

• Confirm hypertension diagnosis using:

  • Office BP measurements (average of readings)
  • Home BP monitoring (threshold ≥135/85 mmHg)
  • 24-hour ambulatory BP monitoring (threshold ≥130/80 mmHg) 1

• Assess for:

  • Cardiovascular disease risk factors
  • Target organ damage
  • Comorbidities (diabetes, chronic kidney disease)
  • Secondary causes of hypertension

Lifestyle Modifications

Lifestyle modifications should be implemented for all patients with hypertension:

• Weight management: Achieve and maintain healthy body mass index (20-25 kg/m²) 2
• Dietary changes:
  • Reduce sodium intake to 1200-2300 mg/day
  • Increase fruits, vegetables, and low-fat dairy products (DASH diet) 2, 3
  • Increase potassium intake 2
• Physical activity: 150 minutes of moderate-intensity exercise weekly 2
• Alcohol moderation: ≤2 drinks/day for men and ≤1 drink/day for women 2

Pharmacological Treatment Algorithm

Grade 1 Hypertension (140-159/90-99 mmHg):

• High-risk patients (CVD, CKD, diabetes, organ damage, or aged 50-80 years): Start drug treatment immediately alongside lifestyle modifications
• Low-risk patients: Trial of lifestyle modifications for 3-6 months; if BP remains elevated, initiate drug therapy 1

Grade 2 Hypertension (≥160/100 mmHg):

• Start drug treatment immediately alongside lifestyle modifications 1

Initial Drug Selection:

For non-black patients:

1. Start with low-dose ACE inhibitor (e.g., lisinopril 10 mg daily) 1, 4 or ARB (e.g., losartan 50 mg daily) 1, 5
2. If inadequate response, increase to full dose
3. Add thiazide/thiazide-like diuretic if needed
4. Add calcium channel blocker if needed 1, 3

For black patients:

1. Start with low-dose ARB (e.g., losartan) or calcium channel blocker
2. Add thiazide/thiazide-like diuretic if needed
3. If inadequate response, increase to full dose 1, 2

Special Populations

• Patients with diabetes or albuminuria: Start with ACE inhibitor or ARB 2
• Elderly patients (≥65 years): Target BP <130 mmHg if tolerated
• Very elderly patients (>80 years): Target BP 140-145 mmHg if well tolerated 2
• Patients with severe hypertension: Consider starting with two-drug combination (usually thiazide-type diuretic plus ACE inhibitor, ARB, or calcium channel blocker) 2, 3

Monitoring and Follow-up

• Check BP control regularly, aiming to achieve target within 3 months
• Monitor renal function and electrolytes within 3 months of starting therapy, especially with ACE inhibitors, ARBs, or diuretics
• Perform annual monitoring of serum creatinine/eGFR and potassium levels 1, 2
• Consider home BP monitoring to guide treatment adjustments

Target Blood Pressure Goals

• For most adults: <130/80 mmHg 2, 3
• For elderly patients: Individualize based on frailty, but aim for <130 mmHg if tolerated 1, 2

Common Pitfalls to Avoid

1. Inadequate initial assessment: Failure to confirm hypertension with multiple readings or home/ambulatory monitoring
2. Monotherapy for severe hypertension: Most patients require multiple medications for adequate control
3. Inappropriate combinations: Avoid dual RAS blockade (e.g., ACE inhibitor + ARB) due to increased risk of renal dysfunction and hyperkalemia 2
4. Neglecting lifestyle modifications: These are foundational and enhance efficacy of pharmacologic therapy 3
5. Insufficient follow-up: Regular monitoring is essential to ensure BP targets are achieved and maintained