What are the recommended treatments for managing hypertension?

Recommended Treatments for Managing Hypertension

The first-line treatment for hypertension should include lifestyle modifications for all patients, followed by combination pharmacological therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1, 2

Diagnosis and Classification

• Hypertension is diagnosed when blood pressure is persistently ≥140/90 mmHg, measured using a validated device with the patient seated, arm at heart level, with at least two measurements at each visit 1, 2
• Classification: Normal (<120/80 mmHg), Elevated/Prehypertension (130-139/80-89 mmHg), Stage 1 (140-159/90-99 mmHg), Stage 2 (≥160/100 mmHg) 2
• Ambulatory or home blood pressure monitoring should be considered for suspected white coat hypertension, with expected values approximately 10/5 mmHg lower than office readings 1, 2

Treatment Thresholds

• Urgent treatment is needed for BP ≥180/110 mmHg 2
• For all patients with confirmed BP ≥140/90 mmHg, prompt initiation of lifestyle measures and pharmacological treatment is recommended 1, 2
• For BP 130-139/80-89 mmHg with high cardiovascular risk, pharmacological treatment should be considered after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 1

Lifestyle Modifications (First-Line for All Patients)

• Weight reduction to achieve ideal body weight for overweight/obese patients 1, 3, 4
• Dietary modifications: reduced sodium intake, increased potassium intake, adherence to a healthy diet pattern (Mediterranean or DASH diet) 1, 3
• Regular physical activity - predominantly dynamic exercise (e.g., brisk walking) 3, 5
• Alcohol moderation: preferably avoid consumption, or limit to maximum of 14 drinks/week for men and 9 drinks/week for women 1, 5
• Smoking cessation for all patients 1
• Stress management for appropriate patients 5, 6

Pharmacological Management

First-Line Drug Therapy

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 1, 2
• Preferred combinations include a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic 1, 2
• First-line drug classes include:
  • ACE inhibitors or ARBs (e.g., losartan) 7
  • Calcium channel blockers (dihydropyridines) 1
  • Thiazide or thiazide-like diuretics (e.g., chlorthalidone, indapamide) 1, 3

Treatment Strategy

• Fixed-dose single-pill combinations are recommended to improve adherence 1
• If BP is not controlled with a two-drug combination, increase to a three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic) 1
• Beta-blockers should be used when there are specific indications (e.g., angina, post-myocardial infarction, heart failure) 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) 1

Blood Pressure Targets

• For most adults: Target systolic BP 120-129 mmHg, provided treatment is well tolerated 1
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease: Target BP <130/80 mmHg 1, 2
• For elderly patients (≥80 years): Maintain BP-lowering treatment if well tolerated 1
• If target BP cannot be achieved due to poor tolerance, aim for "as low as reasonably achievable" (ALARA principle) 1

Special Populations

Coronary Artery Disease

• Target BP <130/80 mmHg (<140/80 in elderly) 1
• RAS blockers, beta-blockers with or without CCBs are first-line drugs 1
• Consider lipid-lowering treatment with LDL-C target <55 mg/dL (1.4 mmol/L) 1
• Antiplatelet treatment with aspirin is routinely recommended 1

Previous Stroke

• Target BP <130/80 mmHg (<140/80 in elderly) 1
• RAS blockers, CCBs, and diuretics are first-line drugs 1
• Consider lipid-lowering treatment with LDL-C target <70 mg/dL (1.8 mmol/L) for ischemic stroke 1
• Antiplatelet treatment for ischemic stroke but not routinely for hemorrhagic stroke 1

Heart Failure

• Target BP <130/80 mmHg but >120/70 mmHg 1
• RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists are effective 1
• Consider angiotensin receptor-neprilysin inhibitor (ARNI) as an alternative to ACE inhibitors or ARBs 1

Chronic Kidney Disease

• Target BP <130/80 mmHg 1, 2
• RAS blockers are particularly beneficial in patients with proteinuria 7

Adjunctive Therapies

Aspirin

• For secondary prevention of ischemic cardiovascular disease 1
• For primary prevention in patients >50 years with controlled BP (<150/90 mmHg) and high cardiovascular risk (≥20% 10-year risk) 1

Statins

• For all hypertensive patients with established cardiovascular disease 1
• For primary prevention in patients with 10-year cardiovascular risk ≥20% and total cholesterol ≥3.5 mmol/L 1
• Target: Lower total cholesterol by 25% or LDL cholesterol by 30% or reach <4.0 mmol/L or <2.0 mmol/L respectively, whichever is greater 1

Monitoring and Follow-up

• Regular BP monitoring is necessary, with home readings when possible 2
• Allow at least four weeks to observe full response to medication changes 1
• Take medications at the most convenient time of day to establish a habitual pattern and improve adherence 1, 2
• Annual reassessment of cardiovascular risk is recommended 2