Best Approach to Treating Hypertension
The best approach to treating hypertension combines lifestyle modifications with appropriate pharmacological therapy, starting with a thiazide or thiazide-like diuretic, ACE inhibitor/ARB, or calcium channel blocker based on patient characteristics, with the goal of achieving blood pressure <130/80 mmHg for most adults. 1, 2
Initial Assessment and Blood Pressure Targets
- Confirm hypertension diagnosis with accurate office measurements (2-3 readings after 5 minutes of rest) or ambulatory/home monitoring 1, 2
- Target blood pressure goals:
Non-Pharmacological Interventions (First-Line for All Patients)
Non-pharmacological interventions are fundamental for both prevention and management of hypertension 1. These should be implemented for all patients with BP >120/80 mmHg 1:
- Weight loss for overweight/obese patients (5-20 mmHg reduction per 10kg lost) 1, 2
- DASH diet (8-14 mmHg reduction): rich in fruits, vegetables, whole grains, low-fat dairy 1, 2
- Sodium restriction to <2,300 mg/day (2-8 mmHg reduction) 1, 2
- Increased physical activity: at least 150 minutes of moderate-intensity aerobic activity weekly (4-9 mmHg reduction) 1, 2
- Alcohol moderation: limit to ≤1 drink daily for women and ≤2 drinks daily for men (2-4 mmHg reduction) 2
Pharmacological Therapy
When to Initiate Medication
- BP ≥140/90 mmHg: Add pharmacological therapy to lifestyle modifications 1
- BP ≥160/100 mmHg: Initiate with two drugs or single-pill combination 1
First-Line Medication Options
- Thiazide or thiazide-like diuretics (e.g., chlorthalidone preferred over hydrochlorothiazide) 1
- ACE inhibitors (e.g., lisinopril) or ARBs 1, 3
- Calcium channel blockers (e.g., amlodipine) 1
Patient-Specific Considerations
- Black patients: Start with calcium channel blocker or thiazide-like diuretic 2
- Diabetes or CKD: Prefer ACE inhibitor or ARB 1, 2
- History of stroke/TIA: Target lower BP (<140 mmHg systolic) 1
- Older adults (≥60 years): More conservative targets may be appropriate (SBP <150 mmHg) 1
Treatment Algorithm
- Start with lifestyle modifications for all patients with BP >120/80 mmHg 1
- For BP ≥140/90 mmHg: Add single agent from first-line options 1
- Choose based on patient demographics and comorbidities
- Prefer generic medications when available 1
- For BP ≥160/100 mmHg: Start with two-drug combination 1
- If BP remains uncontrolled:
- Optimize dosage of initial medication
- Add second agent from a different class
- Consider fixed-dose combination pills to improve adherence 1
- For resistant hypertension (BP uncontrolled on ≥3 medications):
- Maximize diuretic therapy (switch to chlorthalidone if on hydrochlorothiazide)
- Add mineralocorticoid receptor antagonist (spironolactone)
- Consider specialist referral 1
Monitoring and Follow-up
- Schedule follow-up based on BP level 2:
- BP 130-139/80-89 mmHg: Within 1 month
- BP 140-159/90-99 mmHg: Within 2-4 weeks
- BP ≥160/100 mmHg: Within 1-2 weeks
- Monitor laboratory values (creatinine, eGFR, potassium) 2-4 weeks after starting ACE inhibitors, ARBs, or diuretics 2
- Encourage home BP monitoring to guide medication titration 2
Common Pitfalls to Avoid
- Inadequate BP measurement: Ensure proper technique with validated devices, appropriate cuff size, and patient preparation 2
- Therapeutic inertia: Don't delay intensification of therapy when targets aren't met
- Ignoring adherence issues: Use once-daily dosing and fixed-dose combinations to improve adherence 1
- Overlooking secondary causes: Consider screening for obstructive sleep apnea, primary aldosteronism, renal artery stenosis, or other causes in resistant hypertension 1
- Neglecting lifestyle modifications: These remain essential even when medications are required 1
By following this comprehensive approach that combines appropriate lifestyle modifications with evidence-based pharmacological therapy tailored to patient characteristics, hypertension can be effectively controlled, reducing the risk of cardiovascular events, stroke, and mortality.