What is the best approach to managing hypertension?

Management of Hypertension

The best approach to managing hypertension is a comprehensive strategy that includes lifestyle modifications for all patients with BP >120/80 mmHg and pharmacological therapy starting with a single agent for BP ≥140/90 mmHg or two-drug combination for BP ≥160/100 mmHg, targeting <130/80 mmHg for most patients. 1

Diagnosis and Assessment

• Confirm hypertension with multiple readings at the same visit and across multiple visits
• Consider ambulatory blood pressure monitoring to rule out white coat hypertension
• Initial evaluation should include:
  • Urine analysis for protein
  • Blood electrolytes and creatinine
  • Blood glucose
  • Lipid profile
  • 12-lead ECG

Blood Pressure Targets

• General population: <130/80 mmHg 1, 2
• High-risk patients (diabetes, chronic kidney disease, established cardiovascular disease): <130/80 mmHg 2, 1
• Older adults (≥65 years): SBP 130-139 mmHg 1
• Pregnant women: ≤135/85 mmHg 2

Lifestyle Modifications

For all patients with BP >120/80 mmHg, implement the following lifestyle changes 2, 1:

1. Weight management: Maintain normal BMI (18.5-24.9 kg/m²); each kg lost can reduce SBP by approximately 1 mmHg

2. DASH diet: Rich in fruits, vegetables (8-10 servings/day), and low-fat dairy products (2-3 servings/day); can reduce SBP by 3-11 mmHg 1, 2

3. Sodium restriction: Limit to <2,300 mg/day; can reduce SBP by 3-6 mmHg 2, 1

4. Physical activity: At least 30 minutes of moderate-intensity aerobic activity most days of the week; can reduce SBP by 3-8 mmHg 2, 1

5. Alcohol moderation: No more than 2 drinks/day for men and 1 drink/day for women; can reduce SBP by 2-4 mmHg 2, 1

Pharmacological Therapy

When to Start Medications

• BP ≥140/90 mmHg: Start pharmacological therapy along with lifestyle modifications 2
• BP ≥160/100 mmHg: Immediately start with two-drug combination therapy 2, 1

First-Line Medications

Four main classes with proven cardiovascular benefits 1:

1. ACE inhibitors (e.g., lisinopril): Reduce fatal and non-fatal cardiovascular events 3

2. Angiotensin receptor blockers (ARBs) (e.g., losartan): Particularly beneficial in patients with left ventricular hypertrophy or diabetic nephropathy 4

3. Calcium channel blockers (CCBs) (e.g., amlodipine): Effective across all demographic groups 5

4. Thiazide or thiazide-like diuretics: Cost-effective with proven mortality benefits 1

Combination Therapy Approach

• Initial two-drug combination (for BP ≥160/100 mmHg): ACE inhibitor/ARB + CCB or ACE inhibitor/ARB + thiazide diuretic 1

• Three-drug combination (if BP remains uncontrolled): ACE inhibitor/ARB + CCB + thiazide diuretic 1

• Resistant hypertension (uncontrolled on 3 drugs): Consider adding spironolactone or other agents with different mechanisms 1

Special Populations

African American Patients

• Consider starting with CCB + thiazide diuretic combination 1
• ACE inhibitors and ARBs may be less effective as monotherapy 3, 5

Patients with Diabetes

• Target BP <130/80 mmHg 2
• ACE inhibitors or ARBs preferred as first-line therapy due to renoprotective effects 4

Pregnant Women

• Avoid ACE inhibitors and ARBs (teratogenic)
• Preferred options: labetalol, calcium channel blockers, or methyldopa 1
• Target BP ≤135/85 mmHg 2

Elderly Patients

• Start with lower doses and titrate more slowly
• Target SBP 130-139 mmHg 1
• Be vigilant for orthostatic hypotension

Monitoring and Follow-up

• Check serum creatinine and potassium 7-14 days after initiating ACE inhibitors, ARBs, or diuretics 1
• Follow up every 2-4 weeks until BP is controlled
• Once controlled, follow up at least yearly 1
• Consider home BP monitoring to assess treatment efficacy

Benefits of Treatment

Proper hypertension management significantly reduces the risk of:

• Stroke by 35-40%
• Myocardial infarction by 20-25%
• Heart failure by 50% 2, 1

Common Pitfalls to Avoid

1. Therapeutic inertia: Failure to intensify treatment when BP targets are not met
2. Inadequate dosing: Not titrating medications to effective doses
3. Poor medication adherence: Not addressing side effects or complex regimens
4. Overlooking secondary causes: Not investigating resistant hypertension
5. White coat hypertension: Treating based solely on office readings without confirmation

Remember that the goal of hypertension management is to reduce morbidity and mortality from cardiovascular disease, which requires consistent BP control through a combination of lifestyle changes and appropriate pharmacotherapy.