What is the initial approach to lowering high blood pressure (hypertension) in primary care?

Initial Approach to Lowering High Blood Pressure in Primary Care

The initial approach to lowering high blood pressure in primary care should begin with lifestyle modifications for all patients, followed by pharmacological therapy with a combination of antihypertensive medications when blood pressure remains ≥140/90 mmHg despite lifestyle changes or in patients with high cardiovascular risk. 1

Blood Pressure Classification and Assessment

• Hypertension is defined as blood pressure ≥140/90 mmHg 2, 1
• Elevated blood pressure is defined as systolic BP 120-139 mmHg or diastolic BP 70-89 mmHg 1
• Assess cardiovascular disease risk to guide treatment decisions in all patients with elevated blood pressure 1
• Routine screening is essential for early detection of hypertension, especially in younger patients who may be unaware of their condition 2

First-Line Approach: Lifestyle Modifications

Dietary Changes

• Adopt Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diet patterns, which emphasize fruits, vegetables, and low-fat dairy products while reducing fat and cholesterol 2, 1
• Reduce sodium intake to lower blood pressure, with greater effects seen in those with high baseline intake 2, 3
• Increase potassium intake (0.5-1.0 g/day) through foods like bananas, spinach, and avocados to achieve a favorable sodium-to-potassium ratio of 1.5-2.0 2
• Consider potassium-enriched salt substitutes (75% sodium chloride and 25% potassium chloride) for those without advanced chronic kidney disease 2
• Limit free sugar consumption, especially sugar-sweetened beverages 1

Physical Activity

• Regular aerobic exercise can lower systolic BP by 7-8 mmHg and diastolic BP by 4-5 mmHg 2
• Aerobic (endurance) exercise is recommended as first-line exercise therapy for reducing BP 2
• Dynamic resistance training can provide comparable BP reductions to aerobic exercise, particularly in non-white patients 2
• High-intensity interval training elicits similar BP reductions to moderate continuous exercise while providing greater improvement in physical fitness 2

Weight Management

• Aim for a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Weight loss medications like GLP-1 receptor agonists (e.g., semaglutide) can help reduce BP in obese patients, with studies showing a 5.1 mmHg reduction in systolic BP 2

Alcohol Reduction

• Limit alcohol consumption, preferably avoiding it completely 1
• High-dose alcohol (>30g) can increase blood pressure by 3.7 mmHg systolic and 2.4 mmHg diastolic after 13 hours of consumption 2

Smoking Cessation

• Stop tobacco use and refer to smoking cessation programs 1
• While smoking cessation reduces overall cardiovascular risk, it does not directly reduce blood pressure 2

Pharmacological Treatment

When to Initiate Drug Therapy

• For patients with confirmed hypertension (≥140/90 mmHg), start pharmacological treatment 2, 1
• For patients with elevated BP and high cardiovascular risk, initiate pharmacological treatment if BP remains ≥130/80 mmHg after 3 months of lifestyle intervention 1
• For patients with elevated BP and low/medium cardiovascular risk, continue with lifestyle modifications before considering medication 1

First-Line Drug Therapy

• For most patients with confirmed hypertension, combination therapy is recommended as initial treatment rather than monotherapy 1
• Preferred initial combination: RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination 1
• First-line drug classes with proven efficacy include thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers 2, 4
• Beta-blockers should be reserved for patients with specific indications (angina, post-MI, heart failure, heart rate control) 1

Treatment Escalation

• If BP not controlled with a two-drug combination, escalate to a three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1
• Fixed-dose single-pill combinations improve adherence and should be used when possible 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this is potentially harmful 2

Blood Pressure Targets

• Target systolic BP to 120-129 mmHg for most adults to reduce cardiovascular disease 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

Implementation and Monitoring

• Schedule follow-up visits every 6 months for patients with stable blood pressure control 2
• At follow-up visits: measure blood pressure and weight, inquire about general health and side effects, reinforce lifestyle advice, and check adherence to drug therapy 2
• Consider home BP monitoring to improve control and patient empowerment 1
• Use multidisciplinary approaches including physicians, nurses, pharmacists, dietitians, and physiotherapists 1
• Test for proteinuria annually during follow-up 2

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 potentially harmful 2, 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
• Overlooking the importance of lifestyle modifications even after initiating pharmacological therapy 3