What are the initial management steps for hypertension?

Initial Management of Hypertension

The initial management of hypertension should include both lifestyle modifications and pharmacological therapy, with immediate initiation of drug treatment for patients with BP ≥140/90 mmHg or those at high cardiovascular risk with BP ≥130/80 mmHg. 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 1
• Hypertension is defined as office BP ≥140/90 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, 2

Lifestyle Modifications

• Implement dietary changes following DASH or Mediterranean diet patterns, including reduced sodium intake (<2,300 mg/day), increased potassium intake, and consumption of low-fat dairy products 1, 3
• Encourage regular physical activity with at least 150 minutes of moderate-intensity aerobic activity per week plus resistance training 2-3 times weekly 1, 4
• Recommend weight management with goal of BMI 20-25 kg/m² and healthy waist circumference (<94 cm for men, <80 cm for women) 1, 3
• Advise alcohol moderation with consumption less than 100g/week of pure alcohol, or preferably complete avoidance 1, 4
• Recommend complete smoking cessation with appropriate supportive care 1, 2

Pharmacological Therapy

• Start drug therapy immediately along with lifestyle modifications for patients with BP ≥140/90 mmHg regardless of cardiovascular risk 1
• For patients with BP 130/80-139/89 mmHg, initiate drug therapy immediately if they have high cardiovascular risk (established CVD, CKD, diabetes, target organ damage, or aged 50-80 years) 1
• For most patients with confirmed hypertension, combination therapy is recommended as initial treatment, preferably as a single-pill combination 1, 5
• First-line drug therapy should include:
  • ACE inhibitors or ARBs (e.g., lisinopril starting at 10 mg daily) 6
  • Dihydropyridine calcium channel blockers 1, 5
  • Thiazide or thiazide-like diuretics 1, 5

Treatment Algorithm

1. Initial therapy for most patients with BP ≥140/90 mmHg:

   • Two-drug combination (preferably single-pill) of RAS blocker (ACE inhibitor or ARB) plus either dihydropyridine CCB or thiazide/thiazide-like diuretic 1
   • Consider monotherapy for low-risk grade 1 hypertension, patients >80 years, or frail patients 1

2. For Black patients:

   • Start with ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic 1

3. If BP not controlled with two-drug combination:

   • Increase to three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1

4. If BP still not controlled:

   • Add spironolactone or, if not tolerated, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

BP Targets

• For most adults under 65 years: Target BP <130/80 mmHg 1, 5
• For adults 65-85 years: Target systolic BP 120-129 mmHg if well tolerated 1
• For adults >85 years: Individualize targets based on frailty, with systolic BP 130-139 mmHg if well tolerated 1

Monitoring and Follow-Up

• Monitor BP control with goal of achieving target within 3 months 1
• For patients on ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists, check serum creatinine and potassium 7-14 days after initiation or dose changes 2, 1
• Consider home BP monitoring to guide medication adjustments 2, 7
• Schedule monthly visits until BP target is achieved 2, 1

Special Considerations

• For patients with diabetes, CKD, or established CVD, use ACE inhibitor or ARB as first-line therapy 2, 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this is potentially harmful 1
• Maintain BP-lowering treatment lifelong, even beyond age 85 if well tolerated 1