What are the initial management and treatment guidelines for hypertension?

Initial Management and Treatment Guidelines for Hypertension

The initial management of hypertension should include lifestyle modifications for all patients, with drug therapy initiated in patients with sustained systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥100 mmHg, or in those with lower blood pressures (140-159/90-99 mmHg) who have target organ damage, cardiovascular disease, diabetes, or a 10-year cardiovascular disease risk ≥20%. 1, 2

Diagnosis and Evaluation

• Use validated automated upper arm cuff device with appropriate cuff size
• Patient should be seated with arm at heart level after 5 minutes of rest
• Take at least two measurements per visit
• Consider ambulatory or home blood pressure monitoring to confirm diagnosis when:
  • Clinic BP shows unusual variability
  • Hypertension is resistant to treatment
  • Symptoms suggest hypotension
  • To diagnose "white coat" hypertension 1

Thresholds for Intervention

Blood Pressure (mmHg)	Action
≥160/100	Start drug treatment immediately [1]
140-159/90-99	Start drug treatment if: target organ damage, cardiovascular disease, diabetes, or 10-year CVD risk ≥20%; otherwise, try lifestyle modifications for 3-6 months [1]
<140/90	Lifestyle modifications [1]

Lifestyle Modifications

All patients with hypertension or borderline/high-normal blood pressure should receive advice on:

1. Weight reduction to achieve healthy body weight (BMI 20-25 kg/m²) 1, 2
2. Regular physical activity - 30-60 minutes of moderate aerobic exercise 4-7 days/week 2, 3
3. Sodium restriction - limit to 65-100 mmol/day 1, 4
4. Alcohol moderation - ≤14 units/week for men, ≤9 units/week for women 2, 4
5. Healthy diet - increased fruits, vegetables, low-fat dairy products, reduced saturated fats 2, 3

These lifestyle changes can lower systolic BP by:

• DASH diet: 3-11 mmHg
• Sodium reduction: 3-6 mmHg
• Physical activity: 3-8 mmHg
• Weight management: 1 mmHg per kg lost
• Alcohol limitation: 3-4 mmHg 2

Pharmacological Treatment

First-Line Therapy Options

When drug therapy is indicated, the following are appropriate first-line options:

• Thiazide or thiazide-like diuretics (e.g., chlorthalidone 25 mg daily) 1, 5, 6
• ACE inhibitors (e.g., lisinopril 10 mg daily, except in black patients) 1, 7, 6
• Angiotensin receptor blockers (ARBs) 1, 2
• Calcium channel blockers (CCBs) 1, 2
• Beta-blockers (in patients younger than 60 years) 1, 4

Treatment Algorithm

For non-black patients:

1. Start with low dose ACE inhibitor/ARB
2. If not at target, increase to full dose
3. Add thiazide/thiazide-like diuretic
4. If still not at target, add calcium channel blocker 1, 2

For black patients:

1. Start with ARB + calcium channel blocker or calcium channel blocker + thiazide diuretic
2. Increase to full dose
3. Add diuretic or ACE inhibitor/ARB 1, 2

Special Considerations

• Compelling indications for specific drugs exist (e.g., ACE inhibitors for heart failure, diabetes with nephropathy) 1
• Contraindications must be considered (e.g., avoid thiazides in gout, beta-blockers in asthma, ACE inhibitors/ARBs in pregnancy) 2
• Most patients will require more than one agent to achieve target BP 1, 6
• Consider fixed-dose combinations to improve adherence 1

Blood Pressure Targets

• General population: <140/85 mmHg 1
• Patients with diabetes, chronic kidney disease, or established cardiovascular disease: <130/80 mmHg 1, 2
• Elderly patients (≥65 years): 130-139 mmHg systolic 2
• Minimum acceptable level (audit standard): <150/90 mmHg 1

Monitoring and Follow-up

• Evaluate patients within 1 month of treatment initiation
• Monitor every 2-4 weeks until goal is achieved
• Once target is reached, follow-up every 3-6 months 2
• If BP remains uncontrolled on a three-drug regimen, consider adding spironolactone or refer to a hypertension specialist 2

Additional Cardiovascular Risk Reduction

• Aspirin: 75 mg daily for secondary prevention or primary prevention in patients ≥50 years with controlled BP and high cardiovascular risk 1
• Statins: For all patients with hypertension complicated by cardiovascular disease or with 10-year CVD risk ≥20% 1

By following these guidelines, treatment of hypertension can significantly reduce the risk of stroke by 35-40%, heart attacks by 20-25%, and heart failure by 50% 2.