What is the protocol for managing hypertension (high blood pressure)?

Protocol for Managing High Blood Pressure with Remote Guidelines

For patients with high blood pressure readings, initial management should be based on blood pressure level, with combination therapy recommended as first-line treatment for most patients with BP ≥140/90 mmHg, particularly when initial BP is in grade 2 or 3 range or cardiovascular risk is high. 1

Blood Pressure Assessment and Confirmation

Initial Assessment Based on Screening BP Level:

• BP 120-139/70-89 mmHg:

  • Measure BP out-of-office using ABPM and/or HBPM
  • If not feasible, repeat office measurements on multiple visits 1

• BP 140-159/90-99 mmHg:

  • Confirm diagnosis with out-of-office BP measurement (ABPM/HBPM)
  • If not feasible, confirm with repeated office measurements on multiple visits 1

• BP 160-179/100-109 mmHg:

  • Confirm as soon as possible (within 1 month) preferably with home or ambulatory BP measurements 1

• BP ≥180/110 mmHg:

  • Exclude hypertensive emergency immediately 1, 2
  • Requires prompt treatment and careful monitoring 1

Treatment Approach

Initial Treatment Strategy:

1. For BP 140-159/90-99 mmHg:

   • If low cardiovascular risk: Start with lifestyle modifications for 3-6 months 3
   • If high cardiovascular risk (≥10% 10-year risk), target organ damage, established CVD, diabetes, or CKD: Start drug therapy immediately 1, 3

2. For BP ≥160/100 mmHg:

   • Start drug treatment immediately 3
   • For BP >20/10 mmHg above target: Initiate with two-drug combination 1

Medication Selection:

First-line options:

• Thiazide or thiazide-like diuretics (especially chlorthalidone)
• Calcium channel blockers
• ACE inhibitors
• Angiotensin receptor blockers 1, 3

Effective two-drug combinations:

• ACE inhibitor/ARB + calcium channel blocker (preferred)
• ACE inhibitor/ARB + thiazide diuretic
• Calcium channel blocker + thiazide diuretic 1, 3

For specific populations:

• Black patients: Prefer calcium channel blocker + thiazide diuretic 1, 3
• Elderly patients: Start with lower doses and titrate more slowly 3

Blood Pressure Targets

• General population: <140/90 mmHg 1
• High-risk patients (diabetes, CKD, established CVD): <130/80 mmHg 1, 3
• Elderly (≥65 years): SBP 130-139 mmHg 3

Monitoring and Follow-up

1. After initiating therapy:

   • Monthly evaluation of adherence and therapeutic response until control is achieved 1
   • Check serum creatinine and potassium 7-14 days after starting ACE inhibitors, ARBs, or diuretics 3

2. Once BP is controlled:

   • Follow up at least yearly 3
   • Consider home BP monitoring to assess control 1, 3

Lifestyle Modifications (Concurrent with Medication)

• Sodium restriction: Approximately 2g per day (5g salt) 1, 3
• Physical activity: ≥150 min/week moderate aerobic exercise plus resistance training 2-3 times/week 1, 3
• Weight management: Aim for BMI 20-25 kg/m² and healthy waist circumference (<94 cm men, <80 cm women) 1, 3
• Diet: DASH or Mediterranean diet 3
• Alcohol: Limit to <100g/week of pure alcohol, preferably avoid completely 1
• Smoking: Complete cessation 1, 3

Special Considerations

Hypertensive Urgency (BP ≥180/110 mmHg without acute end-organ damage):

• May be treated with oral antihypertensives as outpatient 2
• Requires close follow-up

Hypertensive Emergency (BP ≥180/110 mmHg with acute end-organ damage):

• Immediate admission to intensive care unit
• Immediate reduction of BP with short-acting titratable IV antihypertensive medication 2
• Appropriate medications: labetalol, esmolol, fenoldopam, nicardipine, clevidipine 2
• Avoid: hydralazine, immediate-release nifedipine, and use sodium nitroprusside with caution 2

Diagnostic Workup for All Hypertensive Patients

• Serum creatinine, eGFR, and urine ACR 1
• 12-lead ECG 1
• Consider echocardiography if ECG abnormalities or cardiac symptoms 1
• Fundoscopy if BP >180/110 mmHg or diabetes 1
• Screen for secondary hypertension if suggestive signs/symptoms 1