What is the initial management for stage 2 hypertension?

Initial Management of Stage 2 Hypertension

For patients with stage 2 hypertension (≥140/90 mmHg), immediate initiation of combination antihypertensive therapy with two agents from different classes is recommended, along with lifestyle modifications. 1

Pharmacological Management

First-Line Combination Therapy

• Start with a combination of two first-line agents:

  • A calcium channel blocker (e.g., amlodipine 5-10 mg daily) AND
  • A thiazide-like diuretic (e.g., chlorthalidone 12.5-25 mg daily) 1, 2

• Fixed-dose single-pill combinations are preferred to improve adherence 2

Alternative First-Line Combinations

• RAS blocker (ACE inhibitor or ARB) with either:
  • A dihydropyridine calcium channel blocker OR
  • A thiazide/thiazide-like diuretic 2

Medication Selection Considerations

• For patients with comorbidities:
  • Diabetes: Include an ACE inhibitor or ARB in the regimen 1
  • Heart failure: Include a beta-blocker 2
  • Chronic kidney disease: Include an ACE inhibitor or ARB 1

Dosing Strategy

• Start with standard doses of both medications
• For ACE inhibitors: Lisinopril starting dose 10 mg daily 3
• For ARBs: Losartan starting dose 50 mg daily 4
• Titrate doses as needed based on blood pressure response

Target Blood Pressure

• Target systolic BP: 120-129 mmHg for most adults 2
• For patients with diabetes, renal impairment, or established cardiovascular disease: Target BP ≤130/80 mmHg 2, 1
• For older adults (≥85 years): A less aggressive target may be appropriate if treatment is poorly tolerated 2

Lifestyle Modifications

Implement the following lifestyle changes concurrently with medication:

1. Dietary Approach:

   • DASH diet (rich in fruits, vegetables, low-fat dairy) 2
   • Sodium restriction (<1500 mg/day) 1
   • Potassium supplementation 2

2. Physical Activity:

   • 150 minutes/week of moderate-intensity aerobic exercise 1
   • Dynamic or isometric resistance training 2-3 times/week 2

3. Weight Management:

   • Target BMI 20-25 kg/m² 2
   • Waist circumference <94 cm for men, <80 cm for women 2

4. Alcohol Limitation:

   • Maximum 100g/week of pure alcohol 2
   • Preferably avoid alcohol completely for best health outcomes 2

5. Smoking Cessation:

   • Complete cessation of tobacco use 2
   • Referral to smoking cessation programs 2

Follow-Up and Monitoring

• Schedule follow-up within 1 month of initiating therapy 1
• Check blood pressure, electrolytes, and renal function 2-4 weeks after starting therapy 1
• If BP goal is not achieved after 1 month, intensify therapy by:
  • Increasing doses of current medications, or
  • Adding a third agent (typically a RAS blocker if not already included) 2
• Once BP is controlled, schedule follow-up every 3-6 months 1

Common Pitfalls to Avoid

1. Delayed Treatment:

   • Avoid delaying pharmacological therapy for stage 2 hypertension 1
   • Do not rely solely on lifestyle modifications for stage 2 hypertension 1

2. Inadequate Initial Therapy:

   • Starting with monotherapy is insufficient for most stage 2 hypertension patients 1
   • Avoid combining two RAS blockers (ACE inhibitor and ARB) 2

3. Poor Follow-Up:

   • Inadequate monitoring can lead to prolonged uncontrolled hypertension 1
   • Failure to assess medication adherence is a common reason for treatment failure 2

4. Overlooking Secondary Causes:

   • Consider screening for primary aldosteronism in resistant hypertension 2
   • Evaluate for sleep apnea, renal artery stenosis, and other secondary causes if BP remains uncontrolled 1

By implementing this comprehensive approach to managing stage 2 hypertension, you can effectively reduce blood pressure and minimize the risk of cardiovascular events, stroke, and mortality.