What are the recommended treatments for managing hypertension?

Recommended Treatments for Managing Hypertension

The most effective approach to managing hypertension combines lifestyle modifications with pharmacological therapy, typically starting with a combination of a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker (CCB) or thiazide/thiazide-like diuretic for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1, 2

Diagnosis and Classification

• Hypertension is defined as persistent systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg 1
• Blood pressure should be measured using a validated device with the patient seated, arm at heart level, with at least two measurements at each visit 2
• Classification of blood pressure:
  • Normal: <120/80 mmHg
  • Elevated/Prehypertension: 130-139/80-89 mmHg
  • Stage 1: 140-159/90-99 mmHg
  • Stage 2: ≥160/100 mmHg 2
• Ambulatory or home blood pressure monitoring should be considered for suspected white coat hypertension 1, 2

Lifestyle Modifications

Lifestyle modifications are recommended for all patients with elevated blood pressure and should complement pharmacological therapy: 1, 2, 3

• Weight reduction to achieve ideal body weight 4, 5
• Regular physical activity (predominantly dynamic exercise like brisk walking) 4, 6
• Dietary modifications:
  • Reduced sodium intake (<2g/day) 1
  • Increased potassium intake 3, 5
  • Mediterranean diet or DASH diet (rich in fruits, vegetables, and low-fat dairy products) 1, 7
• Alcohol moderation (≤14 units/week for men, ≤9 units/week for women) or preferably avoidance 1, 5
• Smoking cessation 1
• Stress management techniques when appropriate 5

Pharmacological Treatment

When to Initiate Drug Therapy

• Immediate initiation of drug therapy is recommended for:
  • All patients with confirmed BP ≥140/90 mmHg, regardless of cardiovascular risk 1, 2
  • Patients with elevated BP (130-139/80-89 mmHg) and high cardiovascular risk after 3 months of lifestyle intervention 1
• Urgent treatment is needed for BP ≥180/110 mmHg 2

First-Line Drug Therapy

• First-line drugs include: 1, 2, 3

  • ACE inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Calcium channel blockers (CCBs), particularly dihydropyridines
  • Thiazide or thiazide-like diuretics

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 1, 2

• Preferred combinations include a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide/thiazide-like diuretic 1, 2

• Fixed-dose single-pill combinations are recommended to improve adherence 1

• Beta-blockers are recommended when there are specific indications such as angina, post-myocardial infarction, heart failure with reduced ejection fraction, or for heart rate control 1

Treatment Algorithm

1. Initial therapy: Start with combination of RAS blocker + CCB or thiazide/thiazide-like diuretic 1, 2
2. If BP not controlled: Increase to triple therapy with RAS blocker + CCB + thiazide/thiazide-like diuretic 1
3. If BP still not controlled: Consider adding a fourth agent or referral to a specialist 1

Important Cautions

• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1
• Monitor for orthostatic hypotension, especially in elderly patients 1
• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence 1

Blood Pressure Targets

• For most adults: Target systolic BP 120-129 mmHg 1, 2
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease: Target BP <130/80 mmHg 1, 2
• For elderly patients (≥80 years): Maintain treatment if well tolerated 1, 2

Special Populations and Comorbidities

• Coronary Artery Disease: RAS blockers and beta-blockers are first-line, with or without CCBs 1
• Previous Stroke: RAS blockers, CCBs, and diuretics are first-line 1
• Heart Failure: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists are recommended 1
• Chronic Kidney Disease: RAS blockers are preferred, especially in the presence of proteinuria 8
• Left Ventricular Hypertrophy: ARBs like losartan are indicated to reduce stroke risk (note: this benefit may not apply to Black patients) 8

Additional Cardiovascular Risk Reduction

• Aspirin: Consider low-dose aspirin (75 mg daily) for secondary prevention or primary prevention in patients aged ≥50 years with controlled BP and high cardiovascular risk 1
• Statins: Recommended for patients with established cardiovascular disease or those at high risk (≥20% 10-year risk) 1

Monitoring and Follow-up

• Allow at least four weeks to observe the full response to medication changes 1
• Regular BP monitoring is necessary, with home readings when possible 2
• Annual reassessment of cardiovascular risk is recommended 2
• Evaluate medication adherence at each visit 1

By following this comprehensive approach to hypertension management, focusing on both lifestyle modifications and appropriate pharmacological therapy, the risk of cardiovascular morbidity and mortality can be significantly reduced.