What are the recommended treatments for managing hypertension?

Hypertension Management: Evidence-Based Recommendations

The recommended treatment for hypertension includes lifestyle modifications as the cornerstone of therapy, with pharmacological treatment using combination therapy including a RAS blocker (ACE inhibitor or ARB) with a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1

Diagnosis and Assessment

• 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 blood pressure monitoring is indicated for unusual BP variability, suspected white coat hypertension, or resistant hypertension 2
• Routine investigations should include urine testing, blood electrolytes, creatinine, glucose, cholesterol, and 12-lead ECG 2
• Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions for patients with borderline hypertension 1, 2

Lifestyle Modifications

Lifestyle modifications are recommended for all patients with elevated blood pressure or hypertension:

• Regular aerobic exercise (≥150 min/week of moderate intensity or 75 min/week of vigorous intensity) complemented with resistance training (2-3 times/week) 1
• Weight control targeting healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Dietary modifications:
  • Increased consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids 1
  • Reduced sodium intake (avoid table salt) 1
  • Restricted free sugar consumption (maximum 10% of energy intake) 1
• Alcohol restriction:
  • Men: <14 units/week
  • Women: <8 units/week
  • Preferably avoid alcohol consumption altogether for best health outcomes 1
• Smoking cessation 1

Pharmacological Management

When to Start Medication

• Initiate drug therapy promptly in all patients with confirmed BP ≥140/90 mmHg, regardless of cardiovascular risk 1
• For patients with elevated BP (130-139/80-89 mmHg) and high cardiovascular risk, consider drug therapy after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 1

First-Line Medications

• The most effective first-line agents are 1:
  • ACE inhibitors (e.g., lisinopril) 3
  • ARBs
  • Dihydropyridine calcium channel blockers (e.g., amlodipine) 4
  • Thiazide/thiazide-like diuretics (chlorthalidone, indapamide)

Treatment Strategy

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 1
• Preferred initial combination: RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide/thiazide-like diuretic 1
• Single-pill fixed-dose combinations are recommended to improve adherence 1
• If BP is not controlled with a two-drug combination, progress to a three-drug combination (RAS blocker + CCB + thiazide/thiazide-like diuretic) 1
• For resistant hypertension, add spironolactone as fourth-line therapy 1

Blood Pressure Targets

• For most adults: Target systolic BP 120-129 mmHg and diastolic BP <80 mmHg, provided treatment is well tolerated 1
• For older patients (≥65 years): Target systolic BP 130-139 mmHg 1
• For patients ≥85 years or with symptomatic orthostatic hypotension: Consider more lenient targets (<140/90 mmHg) 1
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease: Target BP <130/80 mmHg 1

Special Populations

Chronic Kidney Disease

• Target systolic BP 120-129 mmHg for patients with eGFR >30 mL/min/1.73m² 1
• RAS blockers are recommended when albuminuria/proteinuria is present 1

Heart Failure

• For HFrEF: Use ACE inhibitor/ARB, beta-blocker, diuretic, and/or MRA 1
• For HFpEF: Consider SGLT2 inhibitors 1

Stroke

• Target systolic BP 120-130 mmHg in patients with history of stroke or TIA 1

Ethnic Considerations

• For Black patients: Initial therapy should include a diuretic or CCB, either alone or in combination with a RAS blocker 1

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis 2
• Not considering white coat hypertension when office readings are elevated 1, 2
• Inadequate dosing or inappropriate combinations of antihypertensive medications 2
• Not addressing lifestyle modifications alongside pharmacological treatment 1
• Overlooking the need for lower BP targets in high-risk patients 1
• Combining two RAS blockers (ACE inhibitor and ARB), which is not recommended 1

Monitoring and Follow-up

• Regular BP monitoring using both office and home readings when possible 1
• Annual reassessment of cardiovascular risk 2
• Lifelong maintenance of BP-lowering treatment if well tolerated, even beyond age 85 1