What is the recommended treatment approach for a patient with hypertension?

Hypertension Management: A Comprehensive Approach

The recommended treatment approach for hypertension should include a combination of lifestyle modifications and pharmacological therapy, with first-line medications being ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics, targeting a blood pressure of 120-129/70-79 mmHg for most adults if tolerated. 1

Diagnosis and Classification

• Hypertension is defined as persistent systolic blood pressure (SBP) ≥130 mmHg or diastolic BP (DBP) ≥80 mmHg 2
• Screen all patients for substances that may increase BP or interfere with BP-lowering medications 1
• Consider seasonal BP variation - BP is typically lower at higher temperatures and higher at lower temperatures (average decline of 5/3 mmHg systolic/diastolic in summer) 1

Lifestyle Modifications (First-Line Approach)

• Salt reduction: Limit sodium intake to less than 100 mEq/24-hour (approximately 2.3g sodium) 1
• Physical activity: At least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise weekly, complemented with resistance training 2-3 times/week 1, 3
• Weight management: Aim for healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1, 4
• Dietary pattern: Follow a diet rich in whole grains, fruits, vegetables, polyunsaturated fats, and dairy products (similar to DASH diet) 1, 2
• Alcohol moderation: Limit to <14 units/week for men and <8 units/week for women, preferably avoiding alcohol completely 1
• Smoking cessation: Stop tobacco use as it strongly and independently causes cardiovascular disease 1
• Stress reduction: Implement stress management techniques and mindfulness practices 1, 4

Pharmacological Treatment

First-Line Medications

• Recommended first-line agents: 1, 2
  • ACE inhibitors (e.g., lisinopril)
  • ARBs (e.g., losartan)
  • Dihydropyridine CCBs (e.g., amlodipine)
  • Thiazide/thiazide-like diuretics (e.g., chlorthalidone, indapamide)

Treatment Strategy

• Initial therapy: For most patients with confirmed hypertension (BP ≥140/90 mmHg), start with combination therapy rather than monotherapy 1
• Preferred combinations: A RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or diuretic 1
• Single-pill combinations: Use fixed-dose single-pill combinations when possible to improve adherence 1
• Three-drug combination: If BP not controlled with two drugs, use a three-drug combination (typically RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic) 1
• Avoid: Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1

Special Populations

• Black patients: Initial treatment should include a diuretic or CCB, either alone or in combination with a RAS blocker 1
• Elderly patients (≥65 years): Target systolic BP to 130-139 mmHg 1
• Very elderly (≥85 years): Consider more lenient targets (<140 mmHg) 1
• Patients with CKD: Use RAS blockers as part of the treatment strategy, especially with albuminuria/proteinuria 1
• Heart failure patients: Include ACE inhibitors, beta-blockers, and diuretics in the regimen 1, 5

Blood Pressure Targets

• General target: 120-129/70-79 mmHg for most adults if well tolerated 1
• Elderly (≥65 years): Target systolic BP of 130-139 mmHg 1
• Special considerations for more lenient targets (e.g., <140/90 mmHg):
  • Pre-treatment symptomatic orthostatic hypotension
  • Age ≥85 years
  • Moderate to severe frailty
  • Limited life expectancy (<3 years) 1

Management of Resistant Hypertension

• Definition: BP remains above goal despite adherence to an appropriate three-drug regimen including a diuretic 1
• Approach: 1
  • Reinforce lifestyle measures, especially sodium restriction
  • Add low-dose spironolactone to existing treatment
  • If spironolactone not tolerated, consider eplerenone, higher dose thiazide/thiazide-like diuretic, or loop diuretic
  • Consider adding bisoprolol or doxazosin if needed

Monitoring and Follow-up

• Medication timing: Take medications at the most convenient time of day to establish a habitual pattern and improve adherence 1
• Follow-up: Check BP within 4 weeks of any medication adjustment 6
• Home BP monitoring: Consider using home BP monitoring with a target of <135/85 mmHg 6

Common Pitfalls and Caveats

• Adherence issues: Nonadherence affects 10-80% of hypertensive patients; simplify regimens when possible 1
• Seasonal variation: Consider adjusting treatment during significant temperature changes 1
• Secondary causes: Screen for secondary hypertension in young patients (<40 years) and those with resistant hypertension 1
• Avoid monotherapy: In high-risk patients, combination therapy is more effective 6
• Medication interactions: Be aware of substances that may interfere with BP control 1