What is the treatment for uncontrolled hypertension?

Treatment of Uncontrolled Hypertension

For a patient with uncontrolled hypertension (195/87 mmHg), immediate initiation of combination antihypertensive therapy with two agents from different classes is recommended, along with lifestyle modifications.

Classification and Risk Assessment

A blood pressure of 195/87 mmHg is classified as Stage 2 hypertension (severe) according to the British Hypertension Society guidelines 1. This level of blood pressure significantly increases the risk of cardiovascular morbidity and mortality, requiring prompt intervention.

Initial Treatment Approach

Pharmacological Therapy

1. First-line combination therapy:

   • Start with a combination of two agents from different classes 2:
     • Thiazide-type diuretic (preferably chlorthalidone 12.5-25 mg daily)
     • PLUS one of the following:
       • ACE inhibitor (e.g., lisinopril 10-40 mg daily) 3
       • ARB (e.g., losartan 50 mg daily)
       • Calcium channel blocker (e.g., amlodipine 5-10 mg daily) 4

2. Patient-specific considerations:

   • For Black patients: Thiazide-type diuretic plus calcium channel blocker 2
   • For patients with diabetes or albuminuria: Include an ACE inhibitor or ARB 1, 2
   • For patients with heart failure or previous myocardial infarction: ACE inhibitor or ARB plus beta-blocker 1

Lifestyle Modifications (to be implemented concurrently)

• Sodium restriction to 1200-2300 mg/day 2
• Regular physical activity: 150 minutes of moderate-intensity exercise weekly 2, 5
• Weight loss: Target BMI of 20-25 kg/m² (approximately 1 mmHg SBP reduction per 1 kg weight loss) 2
• Moderated alcohol consumption: ≤2 drinks/day for men and ≤1 drink/day for women 2
• Increased consumption of fruits, vegetables, and low-fat dairy products 2

Follow-up and Monitoring

1. Initial follow-up:

   • Reassess blood pressure within 1 month of starting therapy 2
   • Check electrolytes and renal function 2-4 weeks after starting therapy, especially with ACE inhibitors, ARBs, or diuretics 2

2. Subsequent management:

   • If BP remains uncontrolled after 1 month, intensify therapy by:
     • Increasing doses of initial medications, or
     • Adding a third agent from a different class 2
   • For resistant hypertension, consider adding spironolactone or other potassium-sparing diuretics 2

Target Blood Pressure Goals

• For most adults: <140/90 mmHg 1
• For high-risk patients (diabetes, chronic kidney disease, cardiovascular disease): <130/80 mmHg 1
• For elderly patients (≥65 years): <130 mmHg if tolerated, or 140-145 mmHg for very elderly patients (>80 years) 2

Important Considerations and Cautions

• Avoid simultaneous use of ACE inhibitor, ARB, and/or renin inhibitor due to increased risk of hyperkalemia and renal dysfunction 2
• Monitor for adverse effects:
  • Thiazide diuretics: Hyponatremia, hypokalemia 2
  • ACE inhibitors/ARBs: Hyperkalemia, acute kidney injury 2
  • Calcium channel blockers: Peripheral edema 4
• Contraindications:
  • ACE inhibitors/ARBs: Pregnancy, bilateral renal artery stenosis 2
  • Non-dihydropyridine CCBs: Heart failure with reduced ejection fraction 2

Hypertensive Crisis Management

If blood pressure is ≥180/120 mmHg with signs of end-organ damage (hypertensive emergency), immediate hospitalization and IV antihypertensive therapy are required 6. Without end-organ damage (hypertensive urgency), oral medications can be used with close follow-up 6.

The prompt and appropriate management of uncontrolled hypertension is crucial to reduce the risk of cardiovascular events, including stroke, myocardial infarction, and heart failure 7, 8. Early intervention with combination therapy has been shown to achieve better blood pressure control and improved outcomes compared to monotherapy or delayed treatment 2.