What is the initial evaluation and management approach for a new patient with stage 1 hypertension?

Initial Evaluation and Management of Stage 1 Hypertension

For a new patient with stage 1 hypertension (140s-150s mmHg), the initial evaluation should include routine laboratory tests, cardiovascular risk assessment, and appropriate pharmacological therapy based on risk stratification.

Initial Laboratory Evaluation

The following routine investigations should be performed for all hypertensive patients:

• Urine strip test for blood and protein 1
• Blood electrolytes and creatinine 1
• Blood glucose 1
• Serum total:HDL cholesterol ratio 1
• 12-lead electrocardiograph 1

Risk Assessment and Treatment Decision

Risk stratification is essential for determining the treatment approach:

• Calculate 10-year cardiovascular disease (CVD) risk using appropriate risk calculators 1
• Assess for target organ damage (heart, kidneys, eyes, brain) 1
• Evaluate for comorbidities that may influence treatment decisions 1

Treatment Approach Based on Risk

For Stage 1 Hypertension (140-159/90-99 mmHg):

• If 10-year CVD risk <10% and no target organ damage or diabetes:

  • Begin with non-pharmacological therapy 1
  • Schedule follow-up in 3-6 months 1

• If 10-year CVD risk ≥10% OR target organ damage OR diabetes present:

  • Initiate both non-pharmacological and pharmacological therapy 1
  • Schedule follow-up in 1 month 1

Non-Pharmacological Interventions

All patients should receive lifestyle modification advice:

• Sodium restriction (<1500 mg/day) 1
• Increased dietary potassium (3500-5000 mg/day) 1
• Weight loss if overweight/obese 1
• Physical activity (90-150 minutes/week of aerobic exercise) 1
• Alcohol moderation (≤2 drinks/day for men, ≤1 for women) 1
• DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy 1

Pharmacological Therapy

When medication is indicated, first-line options include:

• Thiazide or thiazide-like diuretics (e.g., chlorthalidone 12.5-25 mg daily) 1, 2
• ACE inhibitors (e.g., lisinopril 10-40 mg daily) 1, 3, 2
• Angiotensin receptor blockers (ARBs) 1, 2
• Calcium channel blockers (e.g., amlodipine 2.5-10 mg daily) 1, 4, 2

Special Considerations:

• For Black patients: Calcium channel blockers or thiazide diuretics are preferred initial agents 2, 5
• For patients with diabetes or chronic kidney disease: ACE inhibitors or ARBs are preferred 1
• For patients with specific comorbidities, medication selection should be guided by compelling indications 1

Treatment Targets

• For most patients: Target BP <140/85 mmHg 1
• For patients with diabetes, renal impairment, or established cardiovascular disease: Target BP <130/80 mmHg 1

Follow-up Plan

• For patients on non-pharmacological therapy only: Reassess in 3-6 months 1
• For patients starting pharmacological therapy: Follow-up in 1 month 1
• Monitor for medication adherence, side effects, and BP response 1
• Assess electrolytes and renal function 2-4 weeks after initiating ACE inhibitors, ARBs, or diuretics 1

Indications for Specialist Referral

Consider referral in the following situations:

• Suspected secondary hypertension 1
• Resistant hypertension (uncontrolled on ≥3 medications) 1
• Accelerated hypertension or hypertensive emergency 1
• Unusual BP variability or suspected white coat hypertension 1

Common Pitfalls to Avoid

• Failing to confirm hypertension with multiple readings before initiating therapy 1
• Overlooking secondary causes of hypertension in young patients (<30 years) 1, 5
• Inadequate dosing or inappropriate medication combinations 1
• Not accounting for white coat hypertension, which may lead to overtreatment 1
• Neglecting to assess overall cardiovascular risk when making treatment decisions 1