What is the management of choice for a patient newly diagnosed with hypertension?

Management of Newly Diagnosed Hypertension

For patients newly diagnosed with hypertension, the recommended management includes a combination of lifestyle modifications and pharmacological therapy, with first-line drug treatment consisting of a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) combined with either a calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1

Initial Assessment and Diagnosis

• Confirm hypertension diagnosis using validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at first visit 2
• 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) 1
• Assess for target organ damage, cardiovascular risk factors, and potential secondary causes of hypertension 1, 2
• Screen for primary aldosteronism in patients with difficult-to-control or resistant hypertension 1

Lifestyle Modifications

Lifestyle modifications are the cornerstone of hypertension management and should be implemented for all patients:

• Weight management through caloric restriction for overweight/obese patients, aiming for a BMI of 20-25 kg/m² 1, 2
• Follow DASH (Dietary Approaches to Stop Hypertension) eating pattern or Mediterranean diet 1, 3
• Reduce sodium intake (<2,300 mg/day) and increase potassium intake 1, 2
• Regular physical activity: at least 150 minutes of moderate-intensity aerobic activity per week 1, 2
• Alcohol moderation: less than 100g/week of pure alcohol (approximately 7 standard drinks) 1
• Complete smoking cessation 1, 2

Pharmacological Therapy

Initial Drug Selection

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 1
• The preferred first-line combination is a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic 1
• Fixed-dose single-pill combinations are recommended to improve adherence 1
• For Black patients, consider starting with ARB + dihydropyridine calcium channel blocker or calcium channel blocker + thiazide-like diuretic 2

Special Considerations

• For patients aged ≥85 years, those with symptomatic orthostatic hypotension, or moderate-to-severe frailty, consider starting with monotherapy at lower doses 1
• For patients with albuminuria, use ACE inhibitor or ARB as first-line therapy 2
• For patients with established coronary artery disease, use ACE inhibitor or ARB as first-line therapy 2, 4
• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this is potentially harmful 1

Treatment Algorithm

1. Stage 1 Hypertension (140-159/90-99 mmHg):

   • Start with combination of RAS blocker + CCB or thiazide/thiazide-like diuretic 1
   • Use single-pill combination when possible 1
   • Schedule follow-up in 1 month 1

2. Stage 2 Hypertension (≥160/100 mmHg):

   • Start with combination of RAS blocker + CCB or thiazide/thiazide-like diuretic 1
   • Consider three-drug therapy if BP is significantly elevated 1
   • Schedule follow-up in 1 month 1

3. If BP not controlled with two-drug combination:

   • Increase to a three-drug combination: RAS blocker + CCB + thiazide/thiazide-like diuretic 1
   • Preferably use single-pill combination 1

4. If BP still not controlled (resistant hypertension):

   • Add spironolactone as fourth agent 1
   • If spironolactone is not effective or tolerated, consider eplerenone, beta-blocker, or other agents 1

BP Targets and Monitoring

• Target BP for most adults: 120-129/70-79 mmHg 1
• Monitor BP control with a goal of achieving target within 3 months 2
• Consider home BP monitoring to guide medication adjustments 2
• For patients on ACE inhibitors, ARBs, or aldosterone antagonists, monitor serum creatinine and potassium 2-4 weeks after initiation or dose changes 1, 2
• Schedule monthly visits until BP target is achieved 2

Common Pitfalls and Caveats

• Avoid delaying treatment in young adults with hypertension, as they have earlier onset of cardiovascular events compared to those with normal BP 1
• Do not withhold or down-titrate treatment due to asymptomatic orthostatic hypotension, as this is not associated with higher rates of cardiovascular events 1
• Recognize that intensive BP control in older adults may prevent or partially arrest cognitive decline 1
• Be aware that combining two RAS blockers (ACE inhibitor and ARB) is potentially harmful and not recommended 1
• Understand that most patients will require more than one drug to achieve BP goals 4, 5