What are the recommended treatments for managing hypertension?

Recommended Treatments for Managing Hypertension

For most patients with hypertension, a combination of lifestyle modifications and pharmacological therapy using a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic is recommended as initial treatment to effectively lower blood pressure and reduce cardiovascular risk. 1, 2

Lifestyle Modifications

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

• Regular physical activity: ≥150 minutes/week of moderate intensity aerobic exercise complemented with resistance training 2-3 times/week 1, 2
• Weight management: Target healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1, 2
• Dietary modifications: Mediterranean or DASH diets with increased consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids 1, 2
• Sodium restriction: Reduce salt intake, avoid table salt and processed foods 2
• Sugar restriction: Limit free sugar consumption to maximum 10% of energy intake, especially sugar-sweetened beverages 1
• Alcohol moderation: Limit to less than 100g/week of pure alcohol (approximately 7-10 standard drinks) 1
• Smoking cessation: Stop tobacco use and refer to smoking cessation programs 1

Pharmacological Treatment

When to Initiate Drug Therapy

• Promptly initiate drug therapy in all patients with confirmed BP ≥140/90 mmHg, regardless of cardiovascular risk 1, 2
• Consider drug therapy after 3 months of lifestyle intervention for patients with elevated BP (130-139/80-89 mmHg) and high cardiovascular risk if BP remains ≥130/80 mmHg 1, 2

First-line Medications

• Combination therapy is recommended as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg) 1, 2
• Preferred initial combination: RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide/thiazide-like diuretic 1, 2
• Single-pill fixed-dose combinations are recommended to improve adherence 1
• First-line drug classes with proven efficacy in reducing cardiovascular events include:
  • ACE inhibitors or ARBs (e.g., losartan) 3
  • Dihydropyridine calcium channel blockers 1, 4
  • Thiazide or thiazide-like diuretics (e.g., chlorthalidone, indapamide) 1, 4

Treatment Escalation

• 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 2
• Beta-blockers should be combined with other antihypertensive classes when there are specific indications (e.g., angina, post-myocardial infarction, heart failure) 1

Blood Pressure Targets

• Target systolic BP 120-129 mmHg and diastolic BP <80 mmHg for most adults, if well tolerated 1, 2
• For older patients (≥65 years), consider targeting systolic BP 130-139 mmHg 2
• For patients ≥85 years or with symptomatic orthostatic hypotension, consider more lenient targets (<140/90 mmHg) 2
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, target BP <130/80 mmHg 1, 2

Special Populations

Chronic Kidney Disease

• Target systolic BP 120-129 mmHg for patients with eGFR >30 mL/min/1.73m² 2
• RAS blockers are recommended when albuminuria/proteinuria is present 1, 2

Heart Failure

• For HFrEF, use ACE inhibitor/ARB, beta-blocker, diuretic, and/or mineralocorticoid receptor antagonist 1, 2
• For HFpEF, consider SGLT2 inhibitors 2

Coronary Artery Disease

• RAS blockers and beta-blockers are first-line drugs, with or without CCBs 1
• Target BP <130/80 mmHg (<140/80 mmHg in elderly patients) 1

Previous Stroke

• Target systolic BP 120-130 mmHg 1, 2
• RAS blockers, CCBs, and diuretics are first-line drugs 1

Ethnic Considerations

• For Black patients, initial therapy should include a diuretic or CCB, either alone or in combination with a RAS blocker 2

Monitoring and Follow-up

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

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 2
• Inadequate dosing or inappropriate combinations of antihypertensive medications 2
• Not addressing lifestyle modifications alongside pharmacological treatment 1, 2
• Overlooking the need for lower BP targets in high-risk patients 1, 2
• Combining two RAS blockers (ACE inhibitor and ARB), which is not recommended 1