What is the recommended treatment approach for hypertension?

Recommended Treatment Approach for Hypertension

The recommended first-line treatment for hypertension includes lifestyle modifications combined with pharmacological therapy using a combination of ACE inhibitors/ARBs, calcium channel blockers, and thiazide/thiazide-like diuretics, with a target blood pressure of <130/80 mmHg for most patients. 1

Lifestyle Modifications

• Regular physical activity is recommended: 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week, complemented with resistance training 2-3 times weekly 1
• Weight control is essential, aiming for BMI of 20-25 kg/m² and waist circumference <94 cm in men and <80 cm in women 1
• Dietary recommendations include increased consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty acids, and low-fat dairy products with reduced red meat consumption 1
• Alcohol consumption should be restricted to less than 14 units/week for men and less than 8 units/week for women, though avoiding alcohol completely is preferable 1
• Sodium restriction is particularly important, especially in resistant hypertension 1

Pharmacological Treatment

First-Line Medications

• The core recommended drug classes are:

  • ACE inhibitors or ARBs
  • Calcium channel blockers (CCBs), particularly dihydropyridines
  • Thiazide or thiazide-like diuretics (e.g., chlorthalidone, indapamide)
  • Beta-blockers (in specific indications) 1

• Initial treatment strategy:

  • For most patients with confirmed hypertension, upfront low-dose combination therapy is recommended, preferably as a single-pill combination to improve adherence 1
  • Monotherapy may be considered in patients with elevated blood pressure who have an indication for BP-lowering treatment 1
  • In Black patients, initial treatment should include a diuretic or CCB, either alone or in combination with a RAS blocker 1

Treatment Algorithm

1. Initial therapy: Two-drug combination (ACE inhibitor/ARB + CCB or diuretic), preferably as a single-pill combination 1
2. If BP not at target: Triple therapy with ACE inhibitor/ARB + CCB + diuretic 1
3. If BP still not controlled (resistant hypertension):
   • Add spironolactone (first choice) 1
   • If spironolactone is not tolerated, consider eplerenone, higher-dose thiazide/thiazide-like diuretic, loop diuretic, beta-blocker, alpha-blocker, or centrally acting agent 1

Blood Pressure Targets

• General target: <140/90 mmHg as initial objective for all patients 1
• Optimal target for most adults: 120-129/<80 mmHg, if well tolerated 1
• Older patients (≥65 years): Target systolic BP of 130-139 mmHg 1
• Patients with high cardiovascular risk, diabetes, or CKD: Target systolic BP of <130 mmHg 1
• Special populations requiring more lenient targets (e.g., <140/90 mmHg):
  • Patients ≥85 years old
  • Those with symptomatic orthostatic hypotension
  • Patients with moderate to severe frailty
  • Patients with limited life expectancy (<3 years) 1

Special Considerations

• Resistant hypertension management:

  • Reinforce lifestyle measures, especially sodium restriction
  • Add low-dose spironolactone to existing treatment
  • Consider eplerenone if spironolactone is not tolerated
  • Consider beta-blockers, alpha-blockers, or centrally acting agents as needed 1

• Chronic kidney disease:

  • Target systolic BP of 120-129 mmHg in adults with eGFR >30 mL/min/1.73m²
  • RAS blockers are recommended in the presence of albuminuria or proteinuria 1

• Heart failure:

  • In HFrEF, use ACE inhibitors/ARBs, beta-blockers, diuretics, and MRAs
  • In HFpEF, consider SGLT2 inhibitors for their modest BP-lowering properties 1

Common Pitfalls and Caveats

• Avoid combining two RAS blockers (ACE inhibitors and ARBs) due to increased risk of adverse effects 1
• Be cautious with beta-blocker and diuretic combinations in patients at high risk of developing diabetes 1
• Device-based therapies like renal denervation are not recommended for routine treatment outside of clinical studies 1
• For acute hypertensive emergencies, intravenous labetalol, oral methyldopa, or nifedipine are recommended; avoid hydralazine as first-line therapy 1
• Regular monitoring of serum creatinine, eGFR, and potassium levels is essential when using ACE inhibitors, ARBs, or diuretics 1