What are the recommended management strategies for hypertension?

Management Strategies for Hypertension

The recommended management of hypertension includes both lifestyle modifications and pharmacological therapy, with initial treatment typically consisting of a combination of a RAS blocker (ACE inhibitor or ARB) with either a calcium channel blocker or thiazide/thiazide-like diuretic, targeting a blood pressure goal of 120-129/70-79 mmHg for most adults. 1, 2

Diagnosis and Initial Assessment

• Confirm hypertension diagnosis using validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at first visit 1
• 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

Lifestyle Modifications

Lifestyle modifications are the cornerstone of hypertension management and should be recommended to all patients:

• Salt restriction to 5-6g per day (approximately 2,300 mg sodium) 2, 1
• Alcohol moderation to no more than 20-30g of ethanol per day for men and 10-20g for women (approximately 7 standard drinks per week) 2, 1
• Increased consumption of vegetables, fruits, and low-fat dairy products (DASH diet or Mediterranean diet) 2, 1
• Weight reduction to achieve BMI of 20-25 kg/m² and waist circumference <102cm in men and <88cm in women 2, 1
• Regular exercise of at least 30 minutes of moderate dynamic exercise on 5-7 days per week 2
• Smoking cessation with appropriate support and assistance 2, 1

These lifestyle interventions can reduce systolic BP by 3-9 mmHg and diastolic BP by 2-5 mmHg, with even greater reductions in hypertensive patients 2, 3.

Pharmacological Therapy

Initial Treatment Approach

• Combination therapy is recommended as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg) 1, 2
• Preferred first-line combination is a RAS blocker (ACE inhibitor like lisinopril or ARB) with either a dihydropyridine calcium channel blocker (like amlodipine) or thiazide/thiazide-like diuretic 1, 4, 5
• Fixed-dose single-pill combinations are recommended to improve adherence 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this can be 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, 2
2. Stage 2 hypertension (≥160/100 mmHg): Start with combination of RAS blocker + CCB or thiazide/thiazide-like diuretic 1, 2
3. If BP not controlled with two-drug combination, increase to a three-drug combination: RAS blocker + CCB + thiazide/thiazide-like diuretic 1, 2
4. For resistant hypertension: Add spironolactone, or if not tolerated, eplerenone, amiloride, higher dose thiazide/thiazide-like diuretic, or a loop diuretic 2

BP Targets

• General target for most adults: 120-129/70-79 mmHg 1, 2
• Patients with diabetes, renal impairment, or established cardiovascular disease: ≤130/80 mmHg 2
• Patients with CKD (eGFR >30 mL/min/1.73 m²): 120-129 mmHg systolic BP 2
• Patients with stroke or TIA: 120-130 mmHg systolic BP 2

Special Populations

Elderly Patients

• Treatment should be initiated at lower doses and titrated more gradually, with careful monitoring for orthostatic hypotension 1
• Intensive BP control may help prevent or partially arrest cognitive decline 1

Black Patients

• Initial antihypertensive treatment should include a diuretic or a calcium channel blocker, either in combination or with a RAS blocker 2
• For black patients from Sub-Saharan Africa, combination therapy including a CCB with either a thiazide diuretic or a RAS blocker is recommended 2

Patients with Comorbidities

• Heart Failure: ACE inhibitor or ARB, beta-blocker, diuretic, and/or mineralocorticoid receptor antagonist (MRA) 2
• Chronic Kidney Disease: RAS blockers are recommended, particularly in the presence of albuminuria or proteinuria 2
• Coronary Artery Disease: Amlodipine is indicated for chronic stable angina, vasospastic angina, and to reduce risk of hospitalization for angina 4

Monitoring and Follow-up

• Monitor BP control with a goal of achieving target within 3 months 1
• Consider home BP monitoring to guide medication adjustments 1
• Monitor serum creatinine and potassium 2-4 weeks after initiation or dose changes of ACE inhibitors, ARBs, or aldosterone antagonists 1

Common Pitfalls to Avoid

• Delaying treatment in young adults with hypertension, as they have earlier onset of cardiovascular events compared to those with normal BP 1
• Withholding treatment due to asymptomatic orthostatic hypotension, as this is not associated with higher rates of cardiovascular events 1
• Inadequate dosing or failing to add additional medications when BP targets are not achieved 6
• Poor medication adherence, which can be improved through once-daily dosing and fixed-dose combinations 2, 1

Effective hypertension management significantly reduces the risk of cardiovascular events, with a 10 mmHg reduction in systolic BP decreasing risk by approximately 20-30% 6.