What is the treatment algorithm for Hypertension (HTN)?

From the Guidelines

The treatment algorithm for hypertension (HTN) begins with lifestyle modifications for all patients, including weight loss, DASH diet, sodium restriction to <2.3g daily, regular physical activity, and limiting alcohol consumption, as recommended by the 2024 ESC guidelines 1. The initial approach to managing hypertension involves non-pharmacological interventions.

• Lifestyle modifications are crucial and include:
  • Weight loss
  • DASH diet (rich in fruits, vegetables, and low-fat dairy)
  • Sodium restriction to <2.3g daily
  • Regular physical activity
  • Limiting alcohol consumption If blood pressure remains ≥130/80 mmHg, medication therapy should be initiated.
• First-line medications include:
  • Thiazide diuretics (chlorthalidone 12.5-25mg daily or hydrochlorothiazide 12.5-50mg daily)
  • Calcium channel blockers (amlodipine 2.5-10mg daily)
  • ACE inhibitors (lisinopril 10-40mg daily)
  • ARBs (losartan 25-100mg daily) For most patients with stage 1 hypertension (130-139/80-89 mmHg), start with a single agent.
• For stage 2 hypertension (≥140/90 mmHg), begin with two medications from different classes. If blood pressure remains uncontrolled, add a third agent from a different class.
• For resistant hypertension (uncontrolled on three medications including a diuretic), consider adding spironolactone 25-50mg daily or other agents like beta-blockers (bisoprolol) as recommended by the 2024 ESC guidelines 1. Medication choices should be tailored based on comorbidities; for example, ACE inhibitors or ARBs are preferred for patients with diabetes or chronic kidney disease, as supported by older guidelines 1. Regular monitoring is essential, with blood pressure goal typically <130/80 mmHg for most patients.
• Medication adherence should be emphasized as a critical component of successful treatment, and patients should be educated on the importance of adherence 1. In patients with resistant hypertension, catheter-based renal denervation may be considered if performed at a medium-to-high volume center, after a shared risk-benefit discussion and multidisciplinary assessment 1.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

The treatment algorithm for Hypertension (HTN) involves comprehensive cardiovascular risk management, including:

• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake Many patients will require more than one drug to achieve blood pressure goals, and specific advice on goals and management can be found in published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 2.

From the Research

Treatment Algorithm for Hypertension (HTN)

The treatment algorithm for hypertension involves a combination of lifestyle modifications and pharmacologic therapy.

• Lifestyle modifications are the first-line therapy for hypertension, including:
  • Weight loss
  • Healthy dietary pattern with low sodium and high potassium intake
  • Physical activity
  • Moderation or elimination of alcohol consumption 3, 4, 5, 6, 7
• The decision to initiate antihypertensive medication should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 3
• First-line drug therapy for hypertension consists of:
  • Thiazide or thiazide-like diuretics
  • Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers
  • Calcium channel blockers 3, 4, 7
• Blood pressure goals differ according to various guidelines, but evidence strongly supports reducing blood pressure to less than 140/90 mm Hg to reduce the risk of all-cause and cardiovascular mortality in adults with hypertension 4, 7
• Non-pharmacological methods, such as relaxation techniques and avoidance of air pollution, can also be beneficial in managing hypertension 6