Hypertension Management: Comprehensive Approach
The management of hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy with a combination of ACE inhibitor/ARB and calcium channel blocker as first-line treatment for most patients with BP ≥140/90 mmHg. 1
Initial Assessment
Confirm hypertension with multiple readings using validated devices
Initial evaluation should include:
- Urine testing for blood and protein
- Blood electrolytes and creatinine
- Blood glucose
- Serum total:HDL cholesterol ratio
- 12-lead ECG 1
Screen for secondary causes of hypertension, especially in:
Treatment Thresholds
Immediate drug treatment indicated for:
Drug treatment also indicated for:
Lifestyle Modifications
Lifestyle modifications are essential for all patients with hypertension or high-normal blood pressure 2, 1:
| Intervention | Approximate SBP Reduction |
|---|---|
| DASH/Mediterranean diet | 3-11 mmHg |
| Sodium reduction (<2,300 mg/day) | 3-6 mmHg |
| Potassium increase | 3-5 mmHg |
| Physical activity (30-60 min, 5-7 days/week) | 3-8 mmHg |
| Weight management (BMI 20-25 kg/m²) | 1 mmHg per kg lost |
| Alcohol limitation (<14 units/week for men, <8 for women) | 3-4 mmHg |
Additional lifestyle measures:
- Smoking cessation
- Reducing intake of total and saturated fats
- Replacing saturated with monounsaturated fats 2, 1
Pharmacological Treatment
First-Line Therapy:
- Two-drug combination as initial therapy for most patients with BP ≥140/90 mmHg 1
- Preferred combination: ACE inhibitor/ARB + dihydropyridine calcium channel blocker 1
- Alternative combination: ACE inhibitor/ARB + thiazide-like diuretic 1
Special Populations:
- African American patients: Consider starting with calcium channel blocker + thiazide diuretic 1
- Older adults (≥65 years): Start with lower doses and titrate more slowly 1
- Pregnant patients: Avoid ACE inhibitors/ARBs; prefer calcium channel blockers, beta-blockers, or labetalol 1
Compelling Indications for Specific Drugs:
- Heart failure: ACE inhibitors (e.g., lisinopril) 3
- Left ventricular hypertrophy: ARBs (e.g., losartan) 4
- Diabetic nephropathy: ARBs (e.g., losartan) or ACE inhibitors 4, 3
- Post-myocardial infarction: ACE inhibitors (e.g., lisinopril) 3
Treatment Targets
- General population: <140/85 mmHg 2, 1
- Patients with diabetes, chronic kidney disease, or established cardiovascular disease: <130/80 mmHg 2, 1
- Minimum acceptable control (audit standard): <150/90 mmHg 2
- When using ambulatory or home BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents 2
Monitoring and Follow-up
- Monitor BP regularly using home or clinic measurements
- Check serum creatinine and potassium 7-14 days after initiating ACE inhibitors, ARBs, or diuretics
- Follow up at least yearly once BP is controlled 1
- Consider ambulatory or home BP monitoring to confirm diagnosis when:
- Clinic BP shows unusual variability
- Hypertension is resistant to treatment
- Symptoms suggest hypotension
- To diagnose "white coat" hypertension 1
Resistant Hypertension Management
- Defined as BP ≥130/80 mmHg despite adherence to 3 or more antihypertensive agents from different classes at optimal doses, including a diuretic 1
- Consider adding spironolactone, eplerenone, or other agents with different mechanisms of action 1
- Consider referral to a hypertension specialist 1
Benefits of Treatment
Treating hypertension significantly reduces the risk of:
- Stroke by 35-40%
- Heart attacks by 20-25%
- Heart failure by 50% 1
- An SBP reduction of 10 mmHg decreases risk of CVD events by approximately 20-30% 5
Common Pitfalls and Caveats
- Avoid thiazide diuretics in gout
- Avoid beta-blockers in asthma
- Avoid ACE inhibitors/ARBs in pregnancy, bilateral renal artery stenosis, or hyperkalemia 1
- Test for orthostatic hypotension before starting or intensifying treatment, especially in older patients 1
- Despite the benefits of BP control, only 44% of US adults with hypertension have their SBP/DBP controlled to less than 140/90 mmHg 5