What is the treatment for stage 2 hypertension?

Treatment of Stage 2 Hypertension

For stage 2 hypertension (BP ≥160/100 mmHg), patients should be started on a combination of nonpharmacological therapy and antihypertensive drug therapy with two agents of different classes, typically a thiazide-type diuretic plus either an ACE inhibitor, ARB, or calcium channel blocker. 1

Initial Management

Immediate Steps

• Evaluate the patient within 1 month of initial diagnosis
• Initiate combination therapy with 2 agents from different classes
• Schedule follow-up BP evaluation in 1 month 1

Medication Selection

1. First-line combination therapy options:

   • Thiazide-type diuretic (preferably chlorthalidone 12.5-25 mg daily) plus:
     • ACE inhibitor (e.g., lisinopril 10-40 mg daily)
     • ARB (e.g., losartan 50 mg daily)
     • Calcium channel blocker (e.g., amlodipine) 1, 2

2. Patient-specific considerations:

   • For Black patients: Start with a thiazide-type diuretic plus calcium channel blocker 1, 2
   • For patients with diabetes or albuminuria: Include an ACE inhibitor or ARB in the regimen 2
   • For patients with very high BP (≥180/110 mmHg): Prompt evaluation and treatment is essential 1

Nonpharmacological Therapy

All patients with stage 2 hypertension should implement these lifestyle modifications alongside medication:

• Sodium restriction (1200-2300 mg/day)
• Regular physical activity (150 minutes of moderate-intensity exercise weekly)
• Weight loss (approximately 1 mmHg SBP reduction per 1 kg weight loss)
• Limited alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women)
• DASH diet (rich in fruits, vegetables, and low-fat dairy products) 2

Monitoring and Follow-up

• Reassess BP in 1 month after initiating therapy 1
• Check electrolytes and renal function 2-4 weeks after starting therapy, especially with ACE inhibitors, ARBs, or diuretics 1, 2
• Adjust medication doses as needed to achieve target BP
• Consider home BP monitoring to guide treatment adjustments 2

Target Blood Pressure

• For most adults: <130/80 mmHg 2
• For elderly patients (≥65 years): Target SBP <130 mmHg if tolerated 2

Important Considerations and Pitfalls

Medication Precautions

• Avoid simultaneous use of ACE inhibitor, ARB, and/or renin inhibitor due to increased risk of hyperkalemia and renal dysfunction 1, 2
• Monitor for hyponatremia and hypokalemia with thiazide diuretics 1
• Be cautious with ACE inhibitors or ARBs in patients with bilateral renal artery stenosis 1
• Avoid ACE inhibitors in pregnancy 1

Common Pitfalls to Avoid

1. Inadequate initial therapy: Starting with monotherapy in stage 2 hypertension often leads to insufficient BP control
2. Insufficient follow-up: Failing to reassess BP within 1 month may delay necessary treatment adjustments
3. Overlooking medication interactions: Some combinations increase adverse effects
4. Neglecting lifestyle modifications: These are essential components of treatment, not optional add-ons

Special Situations

Very High Blood Pressure (≥180/110 mmHg)

• Requires prompt evaluation and treatment 1
• If no evidence of end-organ damage (hypertensive urgency), can be treated with oral medications 1
• If end-organ damage is present (hypertensive emergency), requires immediate hospitalization and IV medications 3

Resistant Hypertension

• Consider chlorthalidone over hydrochlorothiazide due to greater 24-hour BP reduction 2
• Consider adding spironolactone 25 mg daily to existing regimen 2

By following this comprehensive approach to stage 2 hypertension management, clinicians can effectively reduce blood pressure and minimize the risk of cardiovascular events, stroke, and mortality in their patients.