What are the initial management strategies for hypertension?

Initial Management Strategies for Hypertension

For patients with hypertension, initial management should include lifestyle modifications as first-line therapy, followed by pharmacological treatment with evidence-based medications when blood pressure remains elevated above target levels. 1, 2

Lifestyle Modifications

Lifestyle modifications are the cornerstone of hypertension management and should be recommended for all patients with blood pressure >120/80 mmHg:

• DASH-style eating pattern: Emphasizes fruits, vegetables, whole grains, and low-fat dairy products 1

  • Expected BP reduction: 3-11 mmHg 2

• Sodium reduction: Limit to <2,300 mg/day 1

  • Expected BP reduction: 3-6 mmHg 2

• Weight loss: For overweight/obese individuals

  • Expected BP reduction: 1 mmHg per kg lost 2

• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week plus resistance training 2-3 times weekly 1, 2

  • Expected BP reduction: 3-8 mmHg 2

• Alcohol moderation: No more than 2 drinks/day for men and 1 drink/day for women 1

  • Expected BP reduction: 3-4 mmHg 2

• Smoking cessation: Complete cessation recommended 2

Pharmacological Therapy

When to initiate medication:

• BP 130/80-150/90 mmHg: May begin with a single drug 1
• BP ≥150/90 mmHg: Initial treatment with two antihypertensive medications is recommended 1
• BP ≥160/100 mmHg: Start drug treatment immediately 2

First-line medication options:

1. ACE inhibitors (e.g., lisinopril) 1, 3
2. ARBs (e.g., losartan) 1, 4
3. Thiazide-like diuretics (e.g., chlorthalidone, indapamide) 1
4. Dihydropyridine calcium channel blockers (e.g., amlodipine) 1

Special considerations:

• For patients with albuminuria (UACR ≥30 mg/g): Initial treatment should include an ACE inhibitor or ARB 1
• For patients with established coronary artery disease: ACE inhibitors or ARBs are recommended first-line 1
• For African American patients: Consider starting with calcium channel blocker + thiazide diuretic combination 2
• For pregnant patients: Avoid ACE inhibitors and ARBs; prefer calcium channel blockers, beta-blockers, or labetalol 2

Treatment Algorithm

1. Step 1: Implement lifestyle modifications for all patients with BP >120/80 mmHg 1

2. Step 2: Initiate pharmacotherapy based on BP level:

   • For BP 130/80-150/90 mmHg: Start with single agent from first-line options 1
   • For BP ≥150/90 mmHg: Start with two-drug combination 1

3. Step 3: If BP remains uncontrolled after 1 month:

   • Increase dose of initial medication(s) or
   • Add another first-line agent from a different class 1

4. Step 4: If BP remains uncontrolled on three medications (including a diuretic):

   • Consider adding a mineralocorticoid receptor antagonist 1, 2
   • Consider referral to a hypertension specialist 2

Monitoring and Follow-up

• Monitor BP monthly until control is achieved 2
• Check serum creatinine and potassium 7-14 days after initiating ACE inhibitors, ARBs, or diuretics 1, 2
• Once BP is controlled, follow up at least yearly 2
• Consider home BP monitoring to assess control between office visits 2

Common Pitfalls to Avoid

1. Therapeutic inertia: Failing to intensify treatment when BP remains uncontrolled 1
2. Inadequate dosing: Not titrating medications to effective doses 1
3. Overlooking medication adherence: Poor adherence is a common cause of treatment failure 2
4. Ignoring secondary causes: Consider screening for secondary hypertension in resistant cases 2
5. Neglecting lifestyle modifications: These remain important even after starting medications 1
6. Using ACE inhibitors or ARBs in pregnancy: These are contraindicated due to teratogenicity 1

By following this structured approach to hypertension management, clinicians can effectively reduce cardiovascular risk and improve patient outcomes.