What are the initial steps in managing hypertension?

Initial Management of Hypertension

The initial management of hypertension should include confirming the diagnosis, implementing comprehensive lifestyle modifications, and starting appropriate pharmacological therapy with a goal of achieving target blood pressure within 3 months. 1, 2

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 according to American Heart Association or ≥140/90 mmHg according to European Society of Cardiology, confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 1, 2
• Assess for target organ damage, cardiovascular risk factors, and potential secondary causes of hypertension 1, 2

Lifestyle Modifications

• Implement weight management through caloric restriction for overweight/obese patients with BP >120/80 mmHg 1
• Follow DASH (Dietary Approaches to Stop Hypertension) or Mediterranean eating pattern, including:
  • Reducing sodium intake (<2,300 mg/day)
  • Increasing potassium intake (8-10 servings of fruits and vegetables daily)
  • Consuming low-fat dairy products (2-3 servings daily) 1, 2
• Engage in at least 150 minutes of moderate-intensity aerobic activity per week plus resistance training 2-3 times weekly 1, 2
• Practice alcohol moderation (no more than 2 servings per day for men and 1 serving per day for women, or preferably complete avoidance) 1, 2
• Pursue complete smoking cessation with appropriate supportive care 1, 2

Pharmacological Therapy

When to Start Medications

• Start drug therapy immediately along with lifestyle modifications for patients with BP ≥150/90 mmHg 1
• Start drug therapy immediately in high-risk patients (with cardiovascular disease, chronic kidney disease, diabetes, target organ damage, or aged 50-80 years) with BP 130/80-149/99 mmHg 1, 2
• Consider initial treatment with two antihypertensive medications for more effective BP control in patients with BP ≥150/90 mmHg 1

First-Line Medications

• First-line drug therapy includes:
  • ACE inhibitors (e.g., lisinopril starting at 10 mg daily, titrated to 20-40 mg daily) 1, 3
  • Angiotensin receptor blockers (ARBs) 1
  • Thiazide or thiazide-like diuretics 1, 4
  • Dihydropyridine calcium channel blockers 1

Treatment Algorithm

• For most patients with BP ≥140/90 mmHg, start with a two-drug combination of RAS blocker (ACE inhibitor or ARB) plus either dihydropyridine CCB or thiazide/thiazide-like diuretic 2
• Consider monotherapy for low-risk grade 1 hypertension, patients >80 years, or frail patients 2
• For Black patients, consider starting with ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic 1, 2
• If BP not controlled with two-drug combination, increase to three-drug combination 2
• Add spironolactone (starting at 25 mg daily) or other agents if BP still not controlled 2, 5

BP Targets

• Target BP <130/80 mmHg for most adults under 65 years 2
• Target systolic BP 120-129 mmHg for adults 65-85 years if well tolerated 2
• Individualize targets based on frailty, with systolic BP 130-139 mmHg if well tolerated for adults >85 years 2

Monitoring and Follow-Up

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

Special Considerations

• Use ACE inhibitor or ARB as first-line therapy for patients with diabetes, CKD, albuminuria (UACR ≥30 mg/g), or established CVD 1, 2
• Avoid combination of two RAS blockers as this is potentially harmful 2
• For patients with heart failure, consider starting lisinopril at 5 mg daily when used with diuretics 3

Common Pitfalls to Avoid

• Failing to confirm hypertension diagnosis with out-of-office measurements before initiating therapy 1, 2
• Not assessing for secondary causes of hypertension in resistant cases 1
• Using immediate-release nifedipine in hypertensive urgencies, which can cause unpredictable drops in BP 6
• Neglecting to monitor electrolytes and renal function after starting ACE inhibitors, ARBs, or diuretics 1, 2
• Discontinuing medications once BP is controlled, as hypertension management requires lifelong treatment 2
• Inadequate follow-up leading to therapeutic inertia and poor BP control 1, 2