What are the recommended treatments for managing hypertension?

Recommended Treatments for Managing Hypertension

The recommended first-line treatments for managing hypertension include lifestyle modifications and combination pharmacological therapy with a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB), a dihydropyridine calcium channel blocker (CCB), or a thiazide/thiazide-like diuretic, preferably in a single-pill combination. 1, 2

Diagnosis and Classification

• Hypertension is classified as: Normal (<120/80 mmHg), Prehypertension/Elevated (130-139/80-89 mmHg), Stage 1 (140-159/90-99 mmHg), Stage 2 (≥160/100 mmHg) 2
• Blood pressure should be measured using a validated device with the patient seated, arm at heart level, with at least two measurements at each visit 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 2

Treatment Algorithm

Step 1: Lifestyle Modifications (for all patients)

• Implement dietary changes: adopt DASH diet or Mediterranean diet 1, 3
• Reduce sodium intake and increase potassium intake 1, 3
• Limit alcohol consumption (preferably avoid alcohol; maximum 8-14g per drink) 1, 4
• Regular physical activity (predominantly dynamic exercise like brisk walking) 4, 5
• Weight reduction to achieve ideal body weight 3, 5
• Smoking cessation 1
• Restrict free sugar consumption to maximum 10% of energy intake 1

Step 2: Pharmacological Treatment Thresholds

• Immediate initiation of drug therapy for:
  • BP ≥140/90 mmHg in all adults 1, 2
  • BP ≥130/80 mmHg in patients with high cardiovascular risk, diabetes, renal disease, or target organ damage 1
• For BP 130-139/80-89 mmHg with low/medium CVD risk, consider pharmacological treatment after 3 months of lifestyle intervention if BP remains elevated 1

Step 3: Initial Pharmacological Therapy

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 1, 2
• Preferred combinations:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB 1, 2
  • RAS blocker + thiazide/thiazide-like diuretic 1, 2
• Use fixed-dose single-pill combinations when possible to improve adherence 1
• Exceptions for starting with monotherapy: patients aged ≥85 years, symptomatic orthostatic hypotension, moderate-to-severe frailty 1

Step 4: Treatment Intensification

• If BP is not controlled with a two-drug combination, increase to a three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1
• Do not combine two RAS blockers (ACE inhibitor and ARB) 1
• Beta-blockers should be added when there are specific indications (angina, post-myocardial infarction, heart failure with reduced ejection fraction, or for heart rate control) 1

Blood Pressure Targets

• For most adults: target systolic BP 120-129 mmHg 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 is not achievable due to poor tolerance, aim for "as low as reasonably achievable" (ALARA principle) 1

Special Considerations

Comorbidities

• Coronary Artery Disease: RAS blockers, beta-blockers with or without CCBs are first-line drugs 1
• Previous Stroke: RAS blockers, CCBs, and diuretics are first-line drugs 1
• Heart Failure: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists; consider ARNI (sacubitril-valsartan) 1
• Chronic Kidney Disease: RAS blockers are preferred 1

Additional Cardiovascular Risk Reduction

• Consider aspirin (75mg daily) for secondary prevention of ischemic cardiovascular disease and for primary prevention in people over 50 years with controlled BP and high CVD risk 1
• Consider statins for patients with hypertension and established cardiovascular disease or high CVD risk 1

Monitoring and Follow-up

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

Common Pitfalls to Avoid

• Failing to recognize and address medication non-adherence 1
• Inadequate dosing or inappropriate drug combinations 1
• Neglecting lifestyle modifications when initiating pharmacological therapy 3, 6
• Combining two RAS blockers (ACE inhibitor and ARB) 1
• Discontinuing treatment prematurely (treatment should be maintained lifelong if well tolerated) 1