What is the initial management and treatment approach for hypertension?

Initial Management and Treatment Approach for Hypertension

The initial management of hypertension should include lifestyle modifications for all patients, with immediate initiation of pharmacological therapy (preferably a two-drug combination) for patients with blood pressure ≥140/90 mmHg, targeting a blood pressure of <130/80 mmHg for most adults. 1, 2

Diagnosis and Assessment

• 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) 2
• Use 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 2
• Assess for target organ damage, cardiovascular risk factors, and potential secondary causes of hypertension 2

Lifestyle Modifications

• Implement dietary changes following DASH or Mediterranean diet patterns, including:

  • Reduced sodium intake (<2,300 mg/day) 2, 3
  • Increased potassium intake through fruits and vegetables (8-10 servings/day) 3
  • Increased consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty acids, and low-fat dairy products 1
  • Low consumption of red meat 1

• Engage in regular physical activity:

  • At least 150 minutes of moderate-intensity aerobic activity per week 1, 2
  • Include resistance training 2-3 times weekly 1, 2

• Maintain healthy body weight:

  • Target BMI of 20-25 kg/m² 1, 2
  • Healthy waist circumference (<94 cm in men and <80 cm in women) 1

• Moderate alcohol consumption:

  • Less than 14 units/week for men 1
  • Less than 8 units/week for women 1
  • Preferably avoid alcohol completely for best health outcomes 1

• Complete smoking cessation with appropriate supportive care 2

Pharmacological Therapy

When to Initiate Drug Therapy

• Start drug therapy immediately along with lifestyle modifications for patients with BP ≥140/90 mmHg regardless of cardiovascular risk 1, 2
• Initiate drug therapy immediately if patients have high cardiovascular risk (established CVD, CKD, diabetes, target organ damage, or aged 50-80 years) with BP 130/80-139/89 mmHg 2

Initial Drug Selection

• Use combination therapy as initial treatment, preferably as a single-pill combination 2
• First-line drug therapy includes ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and thiazide or thiazide-like diuretics 1, 2, 4
• 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, start with ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic 2

Treatment Algorithm

1. Start with two-drug combination for most patients (RAS blocker + CCB or thiazide/thiazide-like diuretic) 2
2. If BP not controlled, increase to three-drug combination (RAS blocker + CCB + thiazide/thiazide-like diuretic) 1, 2
3. If BP still not controlled, add spironolactone or, if not tolerated, eplerenone 1
4. If BP remains uncontrolled, consider adding beta-blocker, centrally acting agent, alpha-blocker, or hydralazine 1

BP Targets

• Target BP <140/90 mmHg in all patients as a minimum standard 1
• For most adults, target BP <130/80 mmHg if well tolerated 1, 2
• Target systolic BP 120-129 mmHg for most adults if well tolerated 1, 2
• Target diastolic BP <80 mmHg for all hypertensive patients 1
• For adults 65-85 years, target systolic BP 130-139 mmHg if well tolerated 1, 2
• Consider more lenient targets (e.g., <140/90 mmHg) for patients with frailty, limited life expectancy (<3 years), or age ≥85 years 1

Monitoring and Follow-Up

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

Special Considerations

• Use ACE inhibitor or ARB as first-line therapy for patients with diabetes, CKD, or established CVD 2
• Avoid combination of two RAS blockers as this is potentially harmful 2
• Maintain BP-lowering treatment lifelong, even beyond age 85 if well tolerated 2
• For patients with coronary artery disease, ACE inhibitors or ARBs are recommended as first-line therapy 3
• For patients with heart failure, beta-blockers are indicated in addition to other agents 3

Common Pitfalls and Caveats

• Avoid "therapeutic inertia" - failure to intensify treatment when BP targets are not met 2
• Don't underestimate the importance of lifestyle modifications, which can significantly reduce BP and enhance the efficacy of pharmacological therapy 4
• Be aware that Black patients may be more sensitive to the BP-lowering effects of reduced salt intake, increased potassium intake, and the DASH diet 1
• Monitor for orthostatic hypotension, especially in older adults 1
• Avoid abrupt discontinuation of beta-blockers in patients with coronary artery disease 3
• ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy 3