What are the recommended treatments for managing hypertension?

Recommended Treatments for Managing Hypertension

The first-line treatment for hypertension should include lifestyle modifications for all patients, followed by pharmacological therapy with ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics when blood pressure remains ≥140/90 mmHg, with combination therapy recommended for most patients to achieve target blood pressure <130/80 mmHg. 1

Lifestyle Modifications (First-Line for All Patients)

Lifestyle modifications are essential for all hypertensive patients and can produce significant blood pressure reductions:

• DASH diet: 3-11 mmHg reduction 1
• Sodium reduction: 3-6 mmHg reduction 1
• Increased potassium intake: 3-5 mmHg reduction 1
• Physical activity: 3-8 mmHg reduction (30-60 minutes moderate-intensity aerobic activity 5-7 days/week) 1
• Weight management: 1 mmHg reduction per kg lost 1
• Alcohol limitation: 3-4 mmHg reduction 1

Pharmacological Therapy

When to Initiate Medication

• BP ≥160/100 mmHg: Start drug treatment immediately 1
• 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
• Young adults with stage 1 hypertension without target organ damage: Allow 6-12 months for lifestyle modifications before initiating pharmacotherapy 1

First-Line Medication Options

All equally effective at reducing BP and cardiovascular events 1:

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

Initial Treatment Strategy

For most patients with BP ≥140/90 mmHg, start with a two-drug combination 1:

• Preferred combination: ACE inhibitor/ARB + dihydropyridine calcium channel blocker
• Alternative combination: ACE inhibitor/ARB + thiazide-like diuretic

Blood Pressure Targets

• General population: <140/90 mmHg 4, 1
• Patients with diabetes, CKD, or established cardiovascular disease: <130/80 mmHg 1
• Elderly patients (≥65 years): SBP 130-139 mmHg (start with lower doses and titrate more slowly) 1
• Heart failure patients: <130/80 mmHg but >120/70 mmHg 4

Special Populations

Hypertension with Coronary Artery Disease

• First-line drugs: RAS blockers, beta-blockers with or without CCBs 4
• Target: <130/80 mmHg (<140/80 in elderly patients) 4

Hypertension with Previous Stroke

• First-line drugs: RAS blockers, CCBs, and diuretics 4
• Target: <130/80 mmHg (<140/80 in elderly patients) 4

Hypertension with Heart Failure

• First-line drugs: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 4
• Consider: Angiotensin receptor-neprilysin inhibitor (ARNI; sacubitril-valsartan) as an alternative to ACE inhibitors or ARBs 4

Hypertension with Chronic Kidney Disease

• First-line drugs: RAS blockers (ACE inhibitors or ARBs) 4, 3, 2

African American Patients

• Consider starting with: Calcium channel blocker + thiazide diuretic combination 1

Pregnant Patients

• Avoid: ACE inhibitors and ARBs (teratogenic)
• Prefer: Calcium channel blockers, beta-blockers, or labetalol 1

Management of Resistant Hypertension

Resistant hypertension is defined as BP ≥130/80 mmHg despite adherence to 3 or more antihypertensive agents from different classes at optimal doses, including a diuretic 1.

Management options:

• Consider adding spironolactone, eplerenone, or other agents with different mechanisms of action
• Consider referral to a hypertension specialist 1

Monitoring and Follow-up

• Regular BP monitoring: Using home or clinic measurements 1
• Laboratory monitoring: Check serum creatinine and potassium 7-14 days after initiating ACE inhibitors, ARBs, or diuretics 1
• Follow-up frequency: At least yearly once BP is controlled 1
• Consider ambulatory or home BP monitoring: To confirm diagnosis when clinic BP shows unusual variability, hypertension is resistant to treatment, symptoms suggest hypotension, or to diagnose "white coat" hypertension 1

Treatment Benefits

Treating hypertension significantly reduces the 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% to 30% 5.