What is the management approach for symptoms of hypertension?

Management of Hypertension Symptoms

The management of hypertension symptoms requires a combination of lifestyle modifications for all patients, followed by pharmacological therapy with thiazide-type diuretics, ACE inhibitors/ARBs, or calcium channel blockers as first-line medications when blood pressure remains elevated despite lifestyle changes. 1

Initial Assessment and Blood Pressure Thresholds

• Accurate blood pressure measurement is essential using validated devices with proper technique 2
• Routine investigations should include:
  • Urine strip test for blood and protein
  • Blood electrolytes and creatinine
  • Blood glucose
  • Serum total:HDL cholesterol ratio
  • 12-lead electrocardiograph 2

Blood pressure thresholds for intervention:

• Immediate drug treatment for BP ≥160/100 mmHg 1
• For BP 140-159/90-99 mmHg: Start drug treatment if target organ damage, cardiovascular disease, diabetes, or 10-year CVD risk ≥20% is present; otherwise, try lifestyle modifications for 3-6 months 1
• For BP <140/90 mmHg: Focus on lifestyle modifications 1

Lifestyle Modifications

Lifestyle modifications are recommended for all patients with hypertension and should include:

1. Dietary changes:

   • DASH diet (3-11 mmHg reduction)
   • Sodium reduction (3-6 mmHg reduction)
   • Increased potassium intake (3-5 mmHg reduction)
   • Reduced fat intake, especially saturated fats 1

2. Physical activity:

   • 30-60 minutes of moderate-intensity aerobic activity 5-7 days/week (3-8 mmHg reduction)
   • Complementary resistance training at least 2 days/week 1, 3

3. Weight management:

   • Target BMI between 20-25 kg/m²
   • Waist circumference <94 cm in men and <80 cm in women
   • Expect approximately 1 mmHg reduction per kg lost 1

4. Alcohol limitation:

   • <14 units/week for men
   • <8 units/week for women
   • Can provide 3-4 mmHg reduction 1

5. Smoking cessation 1

Pharmacological Therapy

When lifestyle modifications are insufficient to control blood pressure:

1. First-line medications (equally effective at reducing BP and cardiovascular events):

   • Thiazide or thiazide-like diuretics
   • ACE inhibitors (e.g., lisinopril)
   • Angiotensin receptor blockers (ARBs)
   • Calcium channel blockers (e.g., amlodipine) 1, 4, 5

2. Initial therapy approach:

   • For BP ≥140/90 mmHg: Consider starting with a two-drug combination
   • Preferred combination: ACE inhibitor/ARB + dihydropyridine calcium channel blocker
   • Alternative combination: ACE inhibitor/ARB + thiazide-like diuretic 1

3. Dosage considerations:

   • Start at the lowest recommended dose
   • If first drug is ineffective but well tolerated, increase the dose
   • In mild hypertension, changing to another agent may be better than adding a second drug
   • If first drug is only partially effective, add a second drug from another class 2

Treatment Goals

• General population: <140/90 mmHg 1
• Patients with diabetes, chronic kidney disease, or established cardiovascular disease: <130/80 mmHg 1
• Minimum acceptable control (audit standard): <150/90 mmHg 1
• For home or ambulatory BP measurements, targets should be approximately 10/5 mmHg lower than office BP equivalents 1

Special Populations

1. Older adults (≥65 years):

   • Target SBP 130-139 mmHg
   • Start with lower doses and titrate more slowly 1

2. African American patients:

   • Consider starting with a calcium channel blocker + thiazide diuretic combination 1

3. Pregnant patients:

   • Avoid ACE inhibitors and ARBs due to teratogenicity
   • Prefer calcium channel blockers, beta-blockers, or labetalol 1

Management of Hypertensive Crisis

For hypertensive emergencies (severe hypertension with acute end-organ damage):

• Admit to intensive care unit
• Use short-acting titratable intravenous antihypertensive medications
• Options include labetalol, esmolol, fenoldopam, nicardipine, sodium nitroprusside, and clevidipine
• Avoid hydralazine, immediate-release nifedipine, and use sodium nitroprusside with caution due to toxicity 6

For hypertensive urgencies (severe hypertension with no or minimal end-organ damage):

• May generally be treated with oral antihypertensives as an outpatient 6

Follow-up and Monitoring

• 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
• Initial frequent visits may be required to assess baseline blood pressure
• When treatment is initiated and BP stabilized, three-monthly measurements are usually sufficient 2

Benefits of Treatment

Treating hypertension can significantly reduce:

• 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% 7

Remember that despite the benefits of BP control, only 44% of US adults with hypertension have their BP controlled to less than 140/90 mmHg 7, highlighting the importance of comprehensive management and regular follow-up.