What is the initial management for a patient with uncontrolled hypertension?

Initial Management of Uncontrolled Hypertension

For patients with uncontrolled hypertension (BP ≥140/90 mmHg), the recommended initial management is lifestyle modifications plus combination antihypertensive medication therapy, preferably as a single-pill combination of two agents at low doses. 1, 2

Initial Assessment and Medication Selection

• Office BP ≥140/90 mmHg should be treated with both lifestyle advice and BP-lowering medication 1
• For patients with BP between 140/90 mmHg and 159/99 mmHg, treatment may begin with a single drug, but combination therapy is preferred 1, 2
• For patients with BP ≥160/100 mmHg, initial treatment with two antihypertensive medications is strongly recommended 1
• Single-pill combinations improve medication adherence and should be preferred over separate pills 1

First-line Medication Options

• First-line medications include four major drug classes 1:
  • ACE inhibitors (e.g., lisinopril)
  • Angiotensin receptor blockers (ARBs)
  • Dihydropyridine calcium channel blockers (e.g., amlodipine)
  • Thiazide or thiazide-like diuretics (e.g., chlorthalidone)

Preferred Combinations

• Effective and well-tolerated two-drug combinations include 1:
  • Thiazide diuretic + ACE inhibitor
  • Thiazide diuretic + ARB
  • Calcium antagonist + ACE inhibitor
  • Calcium antagonist + ARB
  • Calcium antagonist + thiazide diuretic

Special Considerations

• In Black patients, initial treatment should include a diuretic or calcium channel blocker, either alone or in combination with a RAS blocker 1
• For patients with diabetes and albuminuria, an ACE inhibitor or ARB is recommended as first-line therapy 1
• For patients with heart failure with reduced ejection fraction, treatment should include an ACE inhibitor (or ARB), beta-blocker, and diuretic/MRA if required 1
• For patients with chronic kidney disease, target systolic BP should be 120-139 mmHg, with RAS blockers recommended in the presence of albuminuria 1

Follow-up and Monitoring

• Monthly visits are recommended until blood pressure target is achieved 1
• For patients treated with ACE inhibitors, ARBs, or diuretics, serum creatinine/eGFR and potassium levels should be monitored at least annually 1
• Home BP monitoring or ambulatory BP monitoring should be used to confirm diagnosis and monitor treatment effectiveness 1

Management of Resistant Hypertension

If BP remains uncontrolled despite a three-drug regimen (including a diuretic), consider:

• Reinforcement of lifestyle measures, especially sodium restriction 1
• Addition of spironolactone at low dose to existing treatment 1
• If spironolactone is not tolerated, consider eplerenone, amiloride, higher dose thiazide/thiazide-like diuretic, or loop diuretic 1
• Addition of bisoprolol or doxazosin if mineralocorticoid receptor antagonists are ineffective 1

Common Pitfalls to Avoid

• Avoid combining two RAS blockers (ACE inhibitors and ARBs), as this combination increases adverse effects without additional benefit 1, 2
• Avoid delaying treatment to complete cardiovascular risk assessment; this can be done after initiation of therapy 2
• Don't use immediate-release nifedipine in hypertensive urgencies due to risk of precipitous BP drop 3
• Avoid hydrochlorothiazide when possible and prefer chlorthalidone or indapamide as they have better evidence for cardiovascular outcomes 1

Lifestyle Modifications

• Sodium restriction to <1500 mg/day or reduction of at least 1000 mg/day 1
• Increased potassium intake (3500-5000 mg/day) 1
• Weight loss if overweight/obese 1
• Physical activity (aerobic or dynamic resistance 90-150 min/week) 1
• Moderation of alcohol intake (≤2 drinks per day in men, ≤1 per day in women) 1
• DASH-like diet rich in fruits, vegetables, whole grains, and low-fat dairy products 1