How to manage hypertension as an outpatient?

Outpatient Management of Hypertension

The optimal approach to managing hypertension in outpatient settings includes lifestyle modifications, appropriate pharmacotherapy with first-line agents (ACE inhibitors/ARBs, calcium channel blockers, or thiazide diuretics), and regular follow-up with blood pressure targets of <130/80 mmHg for most adults. 1

Initial Assessment and Blood Pressure Goals

• Blood pressure targets should generally be <130/80 mmHg for most adults, with consideration for slightly higher targets (by approximately 10 mmHg) in older adults 1
• Thresholds for initiating pharmacological treatment range from >140/90 mmHg to >160/100 mmHg depending on overall cardiovascular risk 1, 2
• Proper BP measurement technique is essential, including repeated measurements and consideration of both arms 1
• Monthly visits are recommended until blood pressure target is achieved 1

Lifestyle Modifications (First-Line for All Patients)

• DASH diet: Emphasize fruits, vegetables, whole grains, low-fat dairy products, with reduced saturated and total fat content (expected SBP reduction: 3-5 mmHg) 1
• Weight loss: Aim for ideal body weight with expected 1 mmHg SBP reduction per 1 kg weight loss 1
• Sodium restriction: Target <1500 mg sodium/day with expected 1-3 mmHg SBP reduction per 1000 mg sodium reduction 1
• Increased potassium intake: Aim for 3500-5000 mg potassium/day through dietary sources 1
• Physical activity: 150 minutes/week of moderate aerobic exercise (30-60 minutes, 5-7 times/week) 1, 3
• Alcohol moderation: Limit to ≤2 standard drinks/day for men and ≤1 standard drink/day for women 1

Pharmacological Management

First-Line Medications

• Four primary first-line medication classes with proven mortality benefits: 1, 2, 4
  • Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide)
  • ACE inhibitors (e.g., lisinopril) or ARBs
  • Long-acting calcium channel blockers (e.g., amlodipine)
  • Beta-blockers (primarily in patients <60 years old)

Medication Selection Strategy

• For stage 1 hypertension (SBP 130-159 mmHg or DBP 80-99 mmHg): Start with monotherapy using any first-line agent 1, 2
• For stage 2 hypertension (SBP ≥160 mmHg or DBP ≥100 mmHg): Consider combination therapy with either an ACE inhibitor/ARB plus a calcium channel blocker or thiazide diuretic 1
• Fixed-dose combinations improve adherence and should be considered 1
• Long-acting formulations are preferred (e.g., amlodipine, chlorthalidone) 1

Special Populations

• Diabetes: Target BP <130/80 mmHg; ACE inhibitors or ARBs preferred 1
• Chronic kidney disease: Target BP <130/80 mmHg; ACE inhibitors or ARBs preferred 1, 5
• Coronary artery disease: Beta-blockers and ACE inhibitors recommended 5
• Heart failure: Beta-blockers and ACE inhibitors recommended 5
• Older adults (≥60-80 years): Consider slightly higher BP targets (by approximately 10 mmHg) and more gradual BP reduction 1, 6
• Frailty, dementia, multi-morbidity: Individualize BP targets to reduce side effects and promote quality of life 1

Follow-Up and Monitoring

• Monthly visits until blood pressure target is achieved 1
• Use 90-day medication refills instead of 30-day when possible 1
• Home blood pressure monitoring is recommended for medication titration and maintenance of BP goals 1
• Follow-up within 1 month for moderately elevated BP and within 1 week for severely elevated BP 1
• Consider telehealth strategies to augment office-based management 1
• Screen for social determinants of health and obstacles to care 1

Common Pitfalls to Avoid

• Therapeutic inertia: Failure to intensify treatment when BP remains above target 1
• Medication non-adherence: Use fixed-dose combinations and 90-day refills to improve adherence 1
• White coat hypertension: Consider out-of-office BP monitoring to confirm diagnosis 1
• Masked hypertension: May require ambulatory BP monitoring for detection 1
• Rapid BP reduction: Avoid decreasing BP by >25% within 6 hours as it may increase risk of adverse events 7
• Inadequate lifestyle counseling: Lifestyle modifications can provide substantial BP reduction and enhance medication efficacy 2, 3

By implementing this comprehensive approach to hypertension management, clinicians can effectively reduce cardiovascular morbidity and mortality in their patients.