Initial Management of Hypertension
The initial management of hypertension should begin with lifestyle modifications for all patients with blood pressure >120/80 mmHg, followed by pharmacological therapy based on blood pressure severity and cardiovascular risk factors. 1
Diagnosis and Assessment
- Confirm hypertension diagnosis using validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at first visit and using the arm with higher readings for subsequent measurements 1
- Hypertension is defined as office BP ≥130/85 mmHg, confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 1
- Assess for target organ damage, cardiovascular risk factors, and potential secondary causes of hypertension 1
Lifestyle Modifications
Lifestyle modifications are the cornerstone of hypertension management and should be implemented for all patients with BP >120/80 mmHg 1:
- Weight management: Achieve and maintain healthy body weight through caloric restriction for overweight/obese patients 1, 2
- Dietary approach: Follow DASH (Dietary Approaches to Stop Hypertension) eating pattern 1, 3
- Reduce sodium intake (<2,300 mg/day)
- Increase potassium intake (8-10 servings of fruits and vegetables daily)
- Consume low-fat dairy products (2-3 servings daily)
- Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week 1, 2
- Alcohol moderation: No more than 2 servings per day for men and 1 serving per day for women 1
- Smoking cessation: Complete cessation for all smokers 1
These lifestyle modifications can reduce systolic BP by 4-11 mmHg and enhance the effectiveness of antihypertensive medications 3, 2.
Pharmacological Therapy
When to Initiate Drug Therapy
BP 130/80-149/99 mmHg:
BP ≥150/90 mmHg:
First-Line Medication Options
First-line drug therapy should include any of these classes 1, 3:
- ACE inhibitors (e.g., lisinopril): Starting dose 10 mg daily, usual range 20-40 mg daily 4
- Angiotensin receptor blockers (ARBs) if ACE inhibitors not tolerated 1
- Thiazide-like diuretics (e.g., chlorthalidone): Starting dose 25 mg daily 5, 3
- Dihydropyridine calcium channel blockers (e.g., amlodipine) 1
Special Considerations
- For patients with albuminuria (UACR ≥30 mg/g): Use ACE inhibitor or ARB as first-line therapy 1
- For patients with established coronary artery disease: Use ACE inhibitor or ARB as first-line therapy 1
- For Black patients: Consider starting with ARB + dihydropyridine calcium channel blocker or calcium channel blocker + thiazide-like diuretic 1
- For patients >80 years or frail: Consider starting with monotherapy at lower doses 1
Monitoring and Follow-Up
- Monitor BP control with target of achieving BP goal within 3 months 1
- For patients on ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists: Monitor serum creatinine and potassium 7-14 days after initiation or dose changes 1
- For patients on diuretics: Monitor for hypokalemia 1
- Consider home BP monitoring to guide medication adjustments 1
- Schedule monthly visits until BP target is achieved 1
Common Pitfalls and Caveats
- ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential who are not using reliable contraception 1
- Single-pill combinations may improve medication adherence 1
- White coat hypertension and masked hypertension can be detected with out-of-office BP measurements 1
- Resistant hypertension (BP ≥130/80 mmHg on ≥3 medications or controlled BP requiring ≥4 medications) requires specialized management 1
- Team-based care, telehealth strategies, and addressing social determinants of health can improve BP control rates 1