What are the initial management and treatment options for Hypertension (HTN)?

Initial Management and Treatment Options for Hypertension (HTN)

The initial management of hypertension should begin with lifestyle modifications for all patients, followed by pharmacologic therapy with thiazide diuretics, ACE inhibitors/ARBs, or calcium channel blockers for those with persistent elevated blood pressure, with treatment intensity based on blood pressure severity and cardiovascular risk. 1, 2, 3

Blood Pressure Targets and Assessment

• Target blood pressure: <130/80 mmHg for adults <65 years; 130-139/80 mmHg for those 65-79 years; 140-150/<80 mmHg for those ≥80 years 2
• For high-risk patients (diabetes, chronic kidney disease, cardiovascular disease): <130/80 mmHg 2
• Confirm hypertension diagnosis using:
  • Office BP measurements
  • Home BP monitoring (threshold ≥135/85 mmHg)
  • 24-hour ambulatory BP monitoring (threshold ≥130/80 mmHg) 2

Step 1: Lifestyle Modifications (First-Line for All Patients)

• Weight management: Achieve and maintain healthy BMI (20-25 kg/m²) 2, 4, 5
• Dietary approach:
  • DASH diet (high in fruits, vegetables, low-fat dairy; low in red meat and fats) 2, 3
  • Sodium restriction (<2,300 mg/day) 2, 3
  • Increase potassium intake 4
• Physical activity: Moderate to vigorous activity 3-5 days/week (30-60 minutes per session) 1, 3, 4
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 2, 4
• Smoking cessation 4, 6
• Stress management 4, 6

Step 2: Pharmacologic Therapy

When to Initiate Medications:

• BP 140-159/90-99 mmHg: Consider single agent after trial of lifestyle modifications 1
• BP ≥160/100 mmHg: Initial treatment with two antihypertensive medications 1
• Persistent elevation despite lifestyle modifications 3
• High cardiovascular risk patients 2

First-Line Medication Options:

1. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)
2. ACE inhibitors (e.g., lisinopril) or ARBs
3. Calcium channel blockers (e.g., amlodipine) 1, 2, 3

Medication Selection Considerations:

• African American patients: May have less robust response to ACE inhibitors; consider starting with thiazide diuretic or calcium channel blocker 1
• Patients with diabetes, CKD, or proteinuria: ACE inhibitor or ARB preferred 1, 2
• Elderly patients: Start with lower doses (half the usual adult dose) and titrate gradually; thiazide diuretics or calcium channel blockers may be preferred for isolated systolic hypertension 2
• Pregnancy/women of childbearing potential: Avoid ACE inhibitors and ARBs; consider calcium channel blockers or beta-blockers 1

Dosing and Titration:

• Start with low dose and titrate every 2-4 weeks based on BP response 1, 7
• For lisinopril: Initial dose 10 mg once daily; usual range 20-40 mg daily 7
• Monitor BP every 4-6 weeks until normalized 1
• Check for orthostatic hypotension before and after initiating therapy, particularly in elderly 2

Step 3: Combination Therapy

• If BP not controlled with a single agent, add a second agent with complementary mechanism 1
• Most patients will require two or more agents to achieve BP control 2
• Consider single-pill combinations to improve adherence 1

Effective Combinations:

• ACE inhibitor or ARB + thiazide diuretic
• ACE inhibitor or ARB + calcium channel blocker
• Calcium channel blocker + thiazide diuretic 1, 2

Combinations to Avoid:

• ACE inhibitor + ARB
• ACE inhibitor or ARB + direct renin inhibitor
• Multiple beta-blockers simultaneously 2

Management of Resistant Hypertension

Resistant hypertension is defined as BP ≥140/90 mmHg despite a therapeutic strategy including:

• Appropriate lifestyle management
• A diuretic and two other antihypertensive drugs with complementary mechanisms at adequate doses 1

For resistant hypertension:

• Evaluate for medication nonadherence, white coat hypertension, and secondary hypertension 1
• Consider adding mineralocorticoid receptor antagonist (e.g., spironolactone 25-50 mg daily) 1, 2
• Monitor for hyperkalemia when adding spironolactone to ACE inhibitor or ARB regimen 2

Monitoring and Follow-up

• Monitor serum creatinine/eGFR and potassium 1-4 weeks after starting ACE inhibitor/ARB therapy 2
• More frequent monitoring if GFR <60 mL/min/1.73m² 2
• Review all medications that may raise BP (e.g., NSAIDs) 2
• Continue lifestyle modifications even when medications are prescribed 4, 8

Special Considerations

• Heart failure: Consider adding spironolactone (25-100 mg daily) 2
• Benign prostatic hyperplasia: Alpha-1 blockers may be considered as second-line agents 2
• Elderly: Avoid overly aggressive BP lowering which can lead to orthostatic hypotension, falls, and reduced organ perfusion 2

Remember that lifestyle modifications should be continued even when antihypertensive medications are prescribed, as they can minimize the number and doses of medications required 8.