What are the recommended management strategies for hypertension?

Hypertension Management Strategies

The management of hypertension should include both lifestyle modifications and pharmacological therapy, with first-line medications including thiazide/thiazide-like diuretics, ACE inhibitors/ARBs, and calcium channel blockers, targeting blood pressure <140/90 mmHg for the general population and <130/80 mmHg for high-risk patients. 1

Diagnosis and Assessment

• Confirm hypertension with multiple readings at the same visit, readings from multiple visits, or ambulatory blood pressure monitoring 1
• Assess for target organ damage and cardiovascular risk factors
• Calculate 10-year cardiovascular disease risk to guide treatment intensity 1
• Basic investigations should include:
  • Urine strip test
  • Blood electrolytes and creatinine
  • Blood glucose
  • Lipid profile
  • 12-lead ECG 1

Lifestyle Modifications

Lifestyle modifications are the cornerstone for prevention and treatment of hypertension and should be recommended for all patients:

1. Dietary Approaches:

   • Follow DASH or Mediterranean diet 2, 1
   • Reduce sodium intake to 5-6g per day (expected SBP reduction: 3-6 mmHg) 2, 1
   • Increase potassium intake (expected SBP reduction: 3-5 mmHg) 1
   • Increase consumption of vegetables, fruits, and low-fat dairy products 2

2. Physical Activity:

   • Engage in at least 30 minutes of moderate-intensity dynamic aerobic exercise on 5-7 days per week 2, 1
   • Consider dynamic resistance training 2-3 days per week 2
   • Expected SBP reduction: 3-8 mmHg 1

3. Weight Management:

   • Aim for BMI <25 kg/m² 2
   • Waist circumference <102 cm in men and <88 cm in women 2
   • Expected SBP reduction: 1 mmHg per kg lost 1

4. Alcohol Moderation:

   • Limit to ≤20-30g ethanol/day for men and ≤10-20g ethanol/day for women 2
   • Expected SBP reduction: 3-4 mmHg 1

5. Smoking Cessation:

   • All smokers should be advised to quit and offered assistance 2

Pharmacological Treatment

When to Initiate Drug Therapy

• 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%; otherwise, try lifestyle modifications for 3-6 months 1
• BP <140/90 mmHg: Focus on lifestyle modifications 1

First-Line Medications

The following drug classes are all suitable for initiation and maintenance of antihypertensive treatment:

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

Treatment Strategy

1. Initial Therapy:

   • The ESC/ESH recommends a two-drug combination as initial therapy for most patients with BP ≥140/90 mmHg 1
   • Preferred combination: ACE inhibitor/ARB + calcium channel blocker
   • Alternative combination: ACE inhibitor/ARB + thiazide-like diuretic 1

2. Special Populations:

   • African American patients: Consider starting with calcium channel blocker + thiazide diuretic 1
   • Older adults (≥65 years): Target SBP 130-139 mmHg, start with lower doses and titrate more slowly 1
   • Patients with diabetes, CKD, or established CVD: Target BP <130/80 mmHg 1
   • Pregnant patients: Avoid ACE inhibitors and ARBs; prefer calcium channel blockers, beta-blockers, or labetalol 1

3. Resistant Hypertension:

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

Monitoring and Follow-up

• Monitor BP regularly using home or clinic measurements 1
• Check serum creatinine and potassium 7-14 days after initiating ACE inhibitors, ARBs, or diuretics 1
• Follow up at least yearly once BP is controlled 1
• Consider ambulatory or home BP monitoring to confirm diagnosis when clinic BP shows unusual variability 1

Benefits of Treatment

Treating hypertension can significantly reduce:

• Stroke risk by 35-40%
• Heart attack risk by 20-25%
• Heart failure risk by 50% 1
• An SBP reduction of 10 mmHg decreases risk of CVD events by approximately 20-30% 3

Common Pitfalls to Avoid

1. Inadequate BP measurement: Ensure proper technique and multiple readings
2. Overlooking white coat hypertension: Use home or ambulatory monitoring when suspected
3. Therapeutic inertia: Don't delay intensifying treatment when targets aren't met
4. Poor medication adherence: Simplify regimens when possible and discuss adherence at each visit
5. Ignoring lifestyle modifications: These remain essential even when medications are prescribed
6. Not considering secondary causes: Especially in resistant hypertension or young patients with severe hypertension

By implementing these evidence-based strategies, clinicians can effectively manage hypertension and reduce the risk of cardiovascular morbidity and mortality in their patients.