What is the recommended approach for complex blood pressure management?

Complex Blood Pressure Management Approach

For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination BP-lowering treatment is recommended as initial therapy, using a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1

Initial Assessment and Treatment Strategy

Blood Pressure Classification and Risk Assessment

• Elevated BP is defined as systolic BP 120-139 mmHg or diastolic BP 70-89 mmHg 1
• Hypertension is defined as BP ≥140/90 mmHg 1
• For patients with elevated BP, assess cardiovascular disease (CVD) risk to guide treatment decisions 1
• In patients with elevated BP and low/medium CVD risk (<10% over 10 years), start with lifestyle modifications 1
• For patients with elevated BP and high CVD risk, after 3 months of lifestyle intervention, start pharmacological treatment if confirmed BP ≥130/80 mmHg 1

First-Line Pharmacological Treatment

• ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics (chlorthalidone, indapamide) have demonstrated the most effective reduction of BP and CVD events 1
• Fixed-dose single-pill combinations improve adherence and should be used when possible 1
• Beta-blockers should be reserved for patients with specific indications (angina, post-MI, HFrEF, heart rate control) 1

Treatment Escalation Algorithm

Step 1: Initial Therapy

• For most patients with confirmed hypertension (≥140/90 mmHg), start with a two-drug combination 1
• Preferred combinations: RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB or thiazide/thiazide-like diuretic 1
• Exceptions: patients ≥85 years, those with orthostatic hypotension, moderate-to-severe frailty 1

Step 2: Inadequate Response

• If BP not controlled with a two-drug combination, escalate to a three-drug combination 1
• Recommended three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1

Step 3: Resistant Hypertension

• If BP remains uncontrolled on three drugs, add spironolactone 1
• If spironolactone is not effective or tolerated, consider eplerenone, beta-blockers, alpha-blockers, or centrally acting agents 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) 1

Blood Pressure Targets

• Target systolic BP to 120-129 mmHg for most adults to reduce CVD risk, if well tolerated 1
• If this target cannot be achieved due to poor tolerance, aim for a systolic BP level that is "as low as reasonably achievable" (ALARA principle) 1
• For patients with diabetes or CKD with eGFR >30 mL/min/1.73m², target systolic BP to 120-129 mmHg 1

Special Populations

Elderly Patients

• For patients <85 years who are not frail, follow the same guidelines as for younger people 1
• Maintain BP-lowering treatment lifelong, even beyond age 85, if well tolerated 1
• Test for orthostatic hypotension before starting or intensifying treatment 1

Patients with Diabetes

• After lifestyle intervention, start pharmacological treatment when confirmed BP ≥130/80 mmHg 1
• Target systolic BP to 120-129 mmHg if tolerated 1

Patients with Chronic Kidney Disease

• For moderate-to-severe CKD with confirmed BP ≥130/80 mmHg, use lifestyle optimization and BP-lowering medication 1
• SGLT2 inhibitors are recommended for hypertensive patients with CKD and eGFR >20 mL/min/1.73m² 1
• RAS blockers are more effective at reducing albuminuria than other agents 1

Patients with Heart Disease

• For post-MI patients: include beta-blockers and RAS blockers 1
• For symptomatic angina: include beta-blockers and/or CCBs 1
• For HFrEF/HFmrEF: use ACE inhibitors/ARBs/ARNi, beta-blockers, MRAs, and SGLT2 inhibitors 1
• For HFpEF: SGLT2 inhibitors are recommended 1

Lifestyle Modifications

• Aim for a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Adopt Mediterranean or DASH diets 1
• Limit alcohol consumption (preferably avoid completely) 1
• Restrict free sugar consumption, especially sugar-sweetened beverages 1
• Stop tobacco use and refer to smoking cessation programs 1
• Engage in regular physical activity including both aerobic and resistance training 1
• Reduce sodium intake 1

Implementation and Adherence

• Take medications at the most convenient time of day to establish a habitual pattern 1
• Use multidisciplinary approaches including physicians, nurses, pharmacists, dietitians, and physiotherapists 1
• Consider home BP monitoring to improve control and patient empowerment 1
• Address the five dimensions of adherence: socio-economic factors, health system factors, therapy-related factors, condition-related factors, and patient-related factors 1

Common Pitfalls to Avoid

• Delaying combination therapy in patients with confirmed hypertension ≥140/90 mmHg 1
• Using monotherapy when combination therapy would be more effective 1
• Combining two RAS blockers (ACE inhibitor and ARB), which is not recommended 1
• Failing to screen for secondary hypertension in adults diagnosed with hypertension before age 40 1
• Discontinuing treatment prematurely - BP-lowering treatment should be maintained lifelong if tolerated 1
• Neglecting lifestyle modifications when pharmacological treatment is initiated 2