What are the recommended treatments for managing hypertension?

Management of Hypertension

The recommended treatment for hypertension includes both lifestyle modifications and pharmacological therapy, with combination drug therapy being the most effective approach for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1

Diagnosis and Assessment

• Blood pressure should be measured routinely at least every five years until age 80, with more frequent monitoring (annually) for those with high-normal values (135-139/85-89 mmHg) 1
• Diagnosis requires multiple measurements over several visits to confirm sustained elevation 1
• Standing blood pressure should be measured in elderly or diabetic patients to exclude orthostatic hypotension 1
• Cardiovascular risk assessment should be performed to guide treatment decisions 1

Treatment Thresholds

• Immediate pharmacological treatment is recommended for:

  • Sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg 1
  • BP ≥140/90 mmHg with high cardiovascular risk, target organ damage, established cardiovascular disease, renal disease, or diabetes 1

• For BP 140-159/90-99 mmHg:

  • With low/medium cardiovascular risk: Try lifestyle modifications for 3 months before initiating drug therapy 1
  • With high cardiovascular risk (≥20% 10-year risk) or target organ damage: Initiate pharmacological treatment promptly 1

Lifestyle Modifications

Lifestyle modifications are recommended for all patients with elevated blood pressure:

• Weight management: Aim for a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1, 2
• Physical activity: 150 minutes of moderate aerobic exercise weekly, complemented with resistance training 2-3 times/week 1, 2
• Dietary changes:
  • Adopt Mediterranean or DASH diet patterns 1
  • Reduce sodium intake 1, 2
  • Increase potassium intake through fruits and vegetables 1, 2
  • Limit free sugar consumption, especially sugar-sweetened beverages 1
• Alcohol moderation: Limit to <100g/week of pure alcohol (preferably avoid completely) 1, 2
• Smoking cessation: Essential for reducing overall cardiovascular risk 1

Pharmacological Treatment

First-line Medications

• Preferred initial therapy for most patients with confirmed hypertension (≥140/90 mmHg) is combination therapy 1
• First-line drug classes with proven efficacy:
  • ACE inhibitors or ARBs (Angiotensin Receptor Blockers) 1, 2
  • Dihydropyridine calcium channel blockers (CCBs) 1, 2
  • Thiazide or thiazide-like diuretics 1, 2

Treatment Strategy

• Initial therapy: Start with a two-drug combination, preferably as a single-pill combination to improve adherence 1

  • Preferred combinations: RAS blocker (ACE inhibitor or ARB) with either a CCB or diuretic 1

• If BP not controlled: Progress to a three-drug combination (RAS blocker + CCB + thiazide/thiazide-like diuretic) 1

• Special considerations:

  • Beta-blockers are recommended when there are specific indications (angina, post-MI, heart failure) 1
  • Never combine two RAS blockers (ACE inhibitor and ARB) 1

Blood Pressure Targets

• General target: Systolic BP 120-129 mmHg, if well tolerated 1
• Minimum acceptable control (audit standard): <150/90 mmHg 1
• For patients with diabetes, renal impairment, or established cardiovascular disease: Target <130/80 mmHg 1
• For elderly patients (≥65 years): Similar targets if well tolerated, with careful monitoring for adverse effects 1

Additional Cardiovascular Risk Reduction

• Aspirin: Recommended for secondary prevention and primary prevention in high-risk patients with controlled BP 1
• Statins: Recommended for patients with established cardiovascular disease or high cardiovascular risk 1

Treatment Adherence Considerations

• Fixed-dose single-pill combinations are recommended to improve adherence 1
• Take medications at the most convenient time of day to establish a habitual pattern 1
• Lifelong treatment is recommended, even beyond age 85 if well tolerated 1

Common Pitfalls to Avoid

• Inadequate BP measurement: Ensure proper technique and multiple readings 1
• Therapeutic inertia: Don't delay treatment intensification when targets aren't met 1
• Ignoring orthostatic hypotension: Always check standing BP in elderly and diabetic patients 1
• Discontinuing medications: BP control requires lifelong treatment in most cases 1
• Combining ACE inhibitors with ARBs: This combination increases adverse effects without additional benefit 1