When should pharmacotherapy be initiated for primary hypertension?

When to Start Pharmacotherapy for Primary Hypertension

Pharmacotherapy for primary hypertension should be initiated promptly when blood pressure is ≥140/90 mmHg, or at ≥130/80 mmHg in patients with high cardiovascular risk, after confirming the diagnosis with repeated measurements. 1

Blood Pressure Thresholds for Treatment Initiation

General Population:

• BP ≥140/90 mmHg: Start pharmacotherapy promptly 1
• BP 130-139/80-89 mmHg: Treatment decisions based on cardiovascular risk:
  • Start pharmacotherapy if:
    • 10-year CVD risk ≥10% 1
    • High-risk conditions present (established CVD, diabetes, CKD, familial hypercholesterolemia, or hypertension-mediated organ damage) 1
    • 10-year CVD risk 5-10% with risk modifiers or abnormal risk tool tests 1
  • Try lifestyle modifications for 3 months first, then add medications if BP remains elevated 1

Special Populations:

• Elderly patients (≥80 years): Start pharmacotherapy when SBP ≥160 mmHg 1
• Elderly patients (<80 years): Consider pharmacotherapy when SBP is 140-159 mmHg if well tolerated 1
• Grade 2-3 hypertension (≥160/100 mmHg): Immediate drug treatment regardless of cardiovascular risk 1

Risk Assessment and Treatment Algorithm

1. Measure BP accurately using standardized techniques with repeated measurements
2. Assess cardiovascular risk using risk calculators (e.g., SCORE) 1
3. Determine treatment threshold based on BP level and risk profile:
   • Low risk + Grade 1 hypertension (140-159/90-99 mmHg): Try lifestyle modifications for several weeks/months before adding medications 1
   • Moderate risk + Grade 1-2 hypertension: Try lifestyle modifications for several weeks before adding medications 1
   • High/very high risk + any grade hypertension: Start pharmacotherapy promptly 1

Lifestyle Modifications

All patients should receive lifestyle recommendations regardless of whether pharmacotherapy is initiated:

• Sodium restriction (<1500 mg/day or reduction of at least 1000 mg/day)
• Increased potassium intake (3500-5000 mg/day)
• Weight loss if overweight/obese
• Physical activity (90-150 min/week aerobic or dynamic resistance)
• Alcohol moderation (≤2 drinks/day for men, ≤1 for women)
• DASH-like diet rich in fruits, vegetables, whole grains, and low-fat dairy 1

Initial Pharmacotherapy Choices

When initiating pharmacotherapy, consider these first-line options:

• Thiazide or thiazide-like diuretics
• ACE inhibitors or ARBs (not to be used simultaneously)
• Calcium channel blockers 1, 2, 3

Special considerations:

• In Black patients: Start with thiazide diuretic or calcium channel blocker 3
• In diabetes with albuminuria: ACE inhibitor or ARB preferred 1
• In heart failure: Beta-blockers, ACE inhibitors or ARBs 1

Common Pitfalls to Avoid

1. Therapeutic inertia: Delaying treatment despite persistent elevated BP
2. Inadequate follow-up: Patients starting medications should be monitored approximately monthly until BP is controlled 1
3. Inappropriate combinations: Avoid combining ACE inhibitors with ARBs 4
4. Ignoring orthostatic hypotension: Check for orthostatic changes before and after initiating therapy, particularly in elderly patients 4
5. Overly aggressive BP lowering in elderly patients, which can lead to falls and reduced organ perfusion 4

Treatment Targets

Once pharmacotherapy is initiated, aim for these targets:

• General population: <140/90 mmHg 1
• High-risk patients (diabetes, CKD, CVD): <130/80 mmHg 1, 4
• Elderly patients (65-79 years): 130-139/80 mmHg 4
• Very elderly patients (≥80 years): 140-150/<80 mmHg 4

Monitoring After Treatment Initiation

• Patients initiating drug therapy should be followed approximately monthly for drug titration until BP is controlled 1
• Monitor for orthostatic hypotension, especially in elderly patients 4
• For patients on ACE inhibitors/ARBs, check serum creatinine/eGFR and potassium 1-4 weeks after starting therapy 4

The decision to initiate pharmacotherapy for primary hypertension should balance the benefits of BP reduction against potential adverse effects, with the ultimate goal of reducing cardiovascular morbidity and mortality.