What is the appropriate approach to managing a patient with hypertension?

Management of Hypertension: A Comprehensive Approach

The appropriate approach to managing hypertension should follow a stepped-care algorithm beginning with lifestyle modifications for all patients, followed by pharmacological therapy with thiazide or thiazide-like diuretics, ACE inhibitors/ARBs, or calcium channel blockers as first-line agents, with treatment goals of <130/80 mmHg for most patients. 1, 2

Initial Assessment and Diagnosis

• Hypertension is defined as persistent systolic blood pressure (SBP) ≥130 mmHg or diastolic BP (DBP) ≥80 mmHg 2
• Essential diagnostic tests include:
  • Urine analysis (Dipstix)
  • Serum electrolyte and urea/creatinine measurements
  • Electrocardiogram (for evidence of myocardial ischemia or left ventricular hypertrophy)
  • Blood glucose measurement 1
• Additional tests to consider: complete blood count, lipid profile, and assessment for secondary causes of hypertension when clinically indicated 1, 3

Lifestyle Modifications

• Lifestyle modifications are recommended for all patients with BP >120/80 mmHg 4, 2
• Key lifestyle interventions include:
  • Weight loss for overweight/obese patients
  • Adoption of DASH-style dietary pattern
  • Sodium restriction (<2300 mg/day)
  • Potassium supplementation (unless contraindicated)
  • Regular physical activity (150 minutes/week of moderate-intensity activity)
  • Limited alcohol consumption (≤1 drink/day for women, ≤2 drinks/day for men) 1, 2
• The BP-lowering effects of individual lifestyle components are partially additive and enhance the efficacy of pharmacologic therapy 2

Pharmacological Therapy

First-Line Medications

• First-line drug therapy for hypertension consists of:
  • Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)
  • ACE inhibitors (e.g., enalapril) or ARBs (e.g., candesartan)
  • Calcium channel blockers (e.g., amlodipine) 1, 2, 5
• Treatment should begin at the lowest recommended dose 1
• In patients with BP >20/10 mmHg above goal, consider initiating therapy with two drugs 1

Treatment Algorithm

1. Step 1: Start with a single agent from one of the first-line classes

   • Chlorthalidone is supported by extensive clinical trial data and may be preferred as initial therapy unless contraindicated 4

2. Step 2: If BP goal is not achieved with monotherapy:

   • Either increase the dose of the initial drug or
   • Add a second agent from a different class 1

3. Step 3: If BP remains uncontrolled, add a third agent from a different class

   • The typical sequence after the first-line agents may include beta-blockers, alpha-blockers, aldosterone antagonists, direct vasodilators, and centrally acting alpha-2 agonists 4

4. Step 4: For resistant hypertension (uncontrolled BP despite ≥3 agents including a diuretic):

   • Consider adding a mineralocorticoid receptor antagonist (spironolactone or eplerenone)
   • Evaluate for secondary causes of hypertension
   • Consider referral to a hypertension specialist 1, 3

BP Treatment Goals

• For most adults: <130/80 mmHg 1, 2
• For adults ≥65 years: SBP <130 mmHg 2
• For patients with diabetes or chronic kidney disease: <130/80 mmHg 1

Special Considerations

Resistant Hypertension

• Defined as BP that remains above goal despite the use of ≥3 antihypertensive medications (including a diuretic) at optimal doses 1, 3
• Management approach:
  • Rule out pseudoresistance (white coat hypertension, improper BP measurement)
  • Assess medication adherence
  • Evaluate for secondary causes of hypertension
  • Consider adding spironolactone as a fourth agent 1, 3

Hypertensive Crisis

• Hypertensive emergency: Severe BP elevation (typically >180/120 mmHg) with evidence of acute target organ damage 6

  • Requires immediate BP reduction (within minutes to hours) with IV medications in an intensive care setting 1, 6
  • Recommended IV agents: labetalol, esmolol, nicardipine, clevidipine, or fenoldopam 1, 6

• Hypertensive urgency: Severe BP elevation without acute target organ damage 6

  • Can be managed with oral medications and close follow-up 1, 6
  • Avoid rapid, uncontrolled BP reduction as this can lead to complications 1

Patient-Centered Care and Follow-Up

• Implement a patient-centered approach that aligns with patient preferences and needs 1
• Discuss potential medication side effects and address patient concerns 1
• Encourage self-monitoring with validated BP devices 1
• Consider cost of therapy and utilize community resources when needed 1
• Schedule follow-up visits every 3 months once BP is stabilized 1
• Consider nurse-managed hypertension clinics, pharmacist involvement, and community outreach workers to improve BP control 1

Common Pitfalls and Caveats

• Avoid rapid and excessive BP lowering in hypertensive emergencies, as this can lead to further complications 1
• Be cautious with ACE inhibitors in patients at risk for angioedema, particularly Black patients 7
• Monitor for hypotension when initiating ACE inhibitors in patients with heart failure, hyponatremia, or those on high-dose diuretics 7
• Consider temporary discontinuation of ACE inhibitors/ARBs before surgery to reduce risk of intraoperative hypotension 1
• Recognize that combination therapy with complementary mechanisms of action is often necessary to achieve BP goals 3
• Be aware that beta-blockers may have adverse effects on metabolic parameters and should be avoided in patients with metabolic syndrome unless specifically indicated 1