What is the management for hypertension?

Management of Hypertension

First-line therapy for hypertension should include lifestyle modifications and appropriate pharmacological treatment with angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), or low-dose thiazide diuretics, with the goal of reducing blood pressure to <130/80 mmHg for most patients. 1, 2

Classification and Goals of Treatment

• Hypertension is categorized as non-elevated BP, elevated BP, and hypertension to guide treatment decisions 1
• The primary goal of treatment is maximum reduction in long-term total risk of cardiovascular morbidity and mortality 1
• Target BP should be <130/80 mmHg for most adults, including those with diabetes and high cardiovascular risk 1, 2
• For older adults (≥65 years), a systolic BP goal of <130 mmHg is recommended, with careful titration and monitoring, especially in those with comorbidities 1

Non-Pharmacological Management

• Lifestyle modifications are recommended as first-line therapy for all patients with elevated blood pressure 2
• Key lifestyle interventions include:
  • Weight loss for overweight or obese patients 2
  • Adoption of a healthy dietary pattern with low sodium and high potassium intake 2
  • Regular physical activity (moderate-intensity aerobic exercise for at least 30 minutes on at least 3 days per week) 3
  • Moderation or elimination of alcohol consumption 2
• These lifestyle modifications can reduce systolic BP by approximately 5 mmHg, which can decrease mortality from coronary heart disease by 9%, stroke by 14%, and all-cause mortality by 7% 3

Pharmacological Management

First-Line Medications

• First-line drug therapy should include one or more of the following classes 2:

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

• For patients with metabolic syndrome, consider:

  • ACE inhibitors or ARBs as first-line therapy 1
  • Add a calcium antagonist if BP is not controlled with monotherapy 1
  • Low-dose thiazide diuretics may be considered as a second or third step 1

Special Populations

• For Black patients, a calcium channel blocker or thiazide diuretic is recommended as initial therapy 4
• For patients with chronic kidney disease, an ACE inhibitor or ARB is recommended as initial or add-on therapy 4
• For patients with diabetes, ACE inhibitors or ARBs are preferred due to their favorable effects on organ damage and lower incidence of diabetes 1

Management of Resistant Hypertension

Resistant hypertension is defined as BP ≥130/80 mmHg despite treatment with 3 or more antihypertensive agents from different classes at optimal doses, including a diuretic, or requiring 4 or more medications to achieve BP control 1.

Approach to Resistant Hypertension:

1. Verify the diagnosis:

   • Ensure accurate office BP measurements 1
   • Assess medication adherence 1
   • Obtain home or ambulatory BP readings to rule out white coat effect 1

2. Address contributing factors:

   • Identify and address lifestyle factors 1
   • Discontinue or minimize substances that interfere with antihypertensive therapy (NSAIDs, stimulants, oral contraceptives) 1
   • Exclude secondary causes of hypertension 1

3. Treatment strategies:

   • Maximize diuretic therapy (use chlorthalidone or indapamide instead of hydrochlorothiazide) 1
   • Add a mineralocorticoid receptor antagonist (spironolactone or eplerenone) 1
   • Add other agents with different mechanisms of action 1
   • Use loop diuretics in patients with chronic kidney disease 1
   • Consider referral to a hypertension specialist if BP remains uncontrolled 1

Management of Hypertensive Emergencies

Hypertensive emergency is defined as BP ≥180/110 mmHg associated with acute hypertension-mediated organ damage 1.

Management approach:

1. Establish affected target organ(s) and whether they require specific interventions beyond BP lowering 1
2. Determine if there is a precipitating cause for the acute rise in BP 1
3. Determine appropriate timing and magnitude of BP reduction 1

• For most hypertensive emergencies, IV treatment with a short half-life drug is recommended to allow careful titration 1
• Avoid rapid, uncontrolled, or excessive BP lowering as this can lead to complications 1
• For specific conditions:
  • In acute intracerebral hemorrhage: Lower systolic BP to 140-160 mmHg, but avoid excessive drops (>70 mmHg) 1
  • In acute ischemic stroke without thrombolysis/thrombectomy: No active BP lowering unless extremely high (>220/120 mmHg) 1
  • In patients receiving thrombolysis: Lower BP to <185/110 mmHg prior to treatment and maintain <180/105 mmHg for 24 hours 1

Improving Treatment Adherence and Control

• Implement a team-based care approach for hypertension management 1
• Consider once-daily dosing of antihypertensive medications and use of combination pills to improve adherence 1
• Home BP monitoring is recommended to achieve better BP control and improve patient empowerment 1
• Use electronic health records and patient registries to recognize uncontrolled hypertension 1
• Consider telehealth strategies as useful adjuncts to interventions for lowering BP 1

Common Pitfalls to Avoid

• Failing to assess medication adherence in patients with uncontrolled hypertension 1
• Not considering secondary causes of hypertension in resistant cases 1
• Using beta-blockers as first-line therapy in patients with metabolic syndrome due to their adverse effects on diabetes incidence, body weight, insulin sensitivity, and lipid profile 1
• Rapid and excessive BP lowering in hypertensive emergencies 1, 5
• Neglecting to evaluate for white coat hypertension or masked hypertension using out-of-office BP measurements 1