Initial Approach to Managing Hypertension
The initial approach to managing hypertension should begin with lifestyle modifications for all patients, followed by thiazide-type diuretics as first-line pharmacological therapy for most patients, either alone or in combination with other antihypertensive drug classes when blood pressure is significantly elevated. 1, 2
Initial Evaluation
- Complete a thorough assessment including:
- Blood tests: electrolytes, creatinine, blood glucose, lipid profile
- Urinalysis: check for protein and blood
- 12-lead ECG
- Assessment for target organ damage
- Evaluation for secondary causes of hypertension, especially in patients <40 years, with resistant hypertension, or sudden onset/worsening 2
Blood Pressure Classification and Treatment Decisions
| BP Classification | Systolic/Diastolic (mmHg) | Initial Management |
|---|---|---|
| Normal | <120/80 | Lifestyle modifications |
| High Normal/Prehypertension | 130-139/85-89 | Lifestyle modifications; drug therapy if diabetes, CVD, CKD, or proteinuria [1] |
| Stage 1 Hypertension | 140-159/90-99 | Lifestyle modifications + drug therapy if target organ damage, CVD, diabetes, or 10-year CVD risk ≥20%; otherwise lifestyle modifications for 3-6 months [2] |
| Stage 2 Hypertension | ≥160/≥100 | Immediate drug therapy + lifestyle modifications [2] |
Lifestyle Modifications
Implement the following lifestyle modifications for all patients with hypertension or high-normal blood pressure 1, 2:
- DASH diet: Emphasize fruits, vegetables, whole grains, low-fat dairy (3-11 mmHg reduction)
- Sodium reduction: Limit to <2300 mg/day (3-6 mmHg reduction)
- Increased potassium intake: Through diet (3-5 mmHg reduction)
- Physical activity: 30-60 minutes of moderate aerobic activity 5-7 days/week (3-8 mmHg reduction)
- Weight management: Target BMI 20-25 kg/m² (1 mmHg reduction per kg lost)
- Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women (3-4 mmHg reduction)
- Smoking cessation
Pharmacological Therapy
When lifestyle modifications are insufficient or immediate drug therapy is indicated:
First-Line Therapy
- Thiazide-type diuretics are recommended as initial therapy for most patients, either alone or in combination with other classes 1
- For BP >20/10 mmHg above goal, consider initiating therapy with two drugs 1
Alternative First-Line Options
- ACE inhibitors (e.g., lisinopril starting at 10 mg daily) 3
- ARBs (e.g., losartan starting at 50 mg daily) 4
- Calcium channel blockers (e.g., amlodipine starting at 5 mg daily) 5
Combination Therapy
- The European Society of Cardiology recommends a two-drug combination as initial therapy for most patients with BP ≥140/90 mmHg 2
- Preferred combinations:
- ACE inhibitor/ARB + calcium channel blocker
- ACE inhibitor/ARB + thiazide-like diuretic
Blood Pressure Targets
- General population: <140/90 mmHg 1, 2
- Patients with diabetes, CKD, or established CVD: <130/80 mmHg 2
- Older adults (≥65 years): Target SBP 130-139 mmHg 2
Special Populations
- African American patients: Consider starting with a calcium channel blocker + thiazide diuretic combination 2
- Pregnant patients: Avoid ACE inhibitors and ARBs; prefer calcium channel blockers, beta-blockers, or labetalol 2
- Patients with comorbidities: Select agents based on compelling indications:
- Heart failure: ACE inhibitors, ARBs, beta-blockers, aldosterone antagonists
- Post-MI: Beta-blockers, ACE inhibitors, aldosterone antagonists
- Diabetes: ACE inhibitors, ARBs
- CKD: ACE inhibitors, ARBs
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 2
- Follow up at least yearly once BP is controlled 2
- Consider ambulatory or home BP monitoring to confirm diagnosis when clinic BP shows unusual variability 2
Common Pitfalls to Avoid
- Underutilization of thiazide diuretics despite their proven efficacy and cost-effectiveness 1
- Inadequate dosing of medications before adding additional agents
- Ignoring lifestyle modifications after starting drug therapy
- Failing to consider secondary causes of hypertension in appropriate patients
- Inappropriate drug combinations: Avoid combining ACE inhibitors with ARBs
- Medication contraindications: Avoid thiazides in gout, beta-blockers in asthma, and ACE inhibitors/ARBs in pregnancy, bilateral renal artery stenosis, or hyperkalemia 2
Treating hypertension effectively can significantly reduce the risk of stroke by 35-40%, heart attacks by 20-25%, and heart failure by 50% 2, making proper management essential for reducing cardiovascular morbidity and mortality.