What are the recommended treatments for managing hypertension?

Management of Hypertension: Evidence-Based Recommendations

The first-line treatment for hypertension should include a combination of lifestyle modifications and pharmacological therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination 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
• Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions for patients with borderline hypertension 2
• All adults should have their blood pressure measured routinely at least every five years until the age of 80 years 1

Lifestyle Modifications

• Regular aerobic exercise (≥150 min/week of moderate intensity) complemented with resistance training (2-3 times/week) 1, 2
• Weight control targeting healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Mediterranean or DASH diet with increased consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids 1
• Reduced sodium intake (avoid table salt) 1, 2
• Restricted free sugar consumption (maximum 10% of energy intake), especially sugar-sweetened beverages 1
• Alcohol restriction to less than 100g/week of pure alcohol 1
• Smoking cessation 1

Pharmacological Management

First-Line Therapy

• 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
• 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

Stepped Care Approach

• 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 drugs 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, provided treatment is well tolerated 1
• For older patients (≥65 years), target 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

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 heart failure with reduced ejection fraction (HFrEF), use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1
• For heart failure with preserved ejection fraction (HFpEF), consider SGLT2 inhibitors 2

Coronary Artery Disease

• BP should be lowered if ≥140/90 mm Hg and treated to a target <130/80 mm Hg (<140/80 in elderly patients) 1
• RAS blockers and beta-blockers are first-line drugs in hypertensive patients with CAD 1

Stroke

• Target systolic BP 120-130 mmHg in patients with history of stroke or TIA 1, 2
• RAS blockers, CCBs, and diuretics are first-line drugs for patients with previous stroke 1

Ethnic Considerations

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

Additional Cardiovascular Risk Reduction

• Consider statin therapy for patients with hypertension and high cardiovascular risk 1
• Consider low-dose aspirin (75 mg/day) for secondary prevention of cardiovascular disease and for primary prevention in people over 50 years with controlled BP and high cardiovascular risk 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 2
• Inadequate dosing or inappropriate combinations of antihypertensive medications 2
• Not addressing lifestyle modifications alongside pharmacological treatment 1, 3
• 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
• Not maintaining BP-lowering treatment lifelong, even beyond age 85, if well tolerated 1

Monitoring and Follow-up

• Regular BP monitoring using both office and home readings when possible 2
• Annual reassessment of cardiovascular risk 2
• Evaluate medication adherence using objective methods when possible 1
• Consider multidisciplinary healthcare team approach to improve monitoring for adherence 1