What is the initial management for a patient with uncontrolled hypertension?

Initial Management of Uncontrolled Hypertension

For patients with uncontrolled hypertension (BP ≥140/90 mmHg), treatment should include both lifestyle modifications and BP-lowering medication, with combination therapy preferred for those with BP ≥160/100 mmHg. 1

Assessment and Treatment Strategy

• Patients with confirmed hypertension and systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg should receive pharmacological treatment 2
• For BP between 140/90 mmHg and 159/99 mmHg, treatment may begin with a single drug, though combination therapy is preferred 1
• For BP ≥160/100 mmHg, initial treatment with two antihypertensive medications is strongly recommended 1
• Single-pill combinations improve medication adherence and should be preferred over separate pills 1

First-Line Medication Options

• First-line medications include four major drug classes 1:

  • ACE inhibitors (e.g., lisinopril)
  • Angiotensin receptor blockers (ARBs)
  • Dihydropyridine calcium channel blockers
  • Thiazide or thiazide-like diuretics

• For lisinopril, the recommended initial dose is 10 mg once daily, with usual dosage range of 20-40 mg per day 3

• If blood pressure is not controlled with an ACE inhibitor alone, a low dose of a diuretic may be added (e.g., hydrochlorothiazide 12.5 mg) 3

Effective Two-Drug Combinations

• Well-tolerated and effective two-drug combinations include 1:

  • Thiazide diuretic + ACE inhibitor
  • Thiazide diuretic + ARB
  • Calcium antagonist + ACE inhibitor
  • Calcium antagonist + ARB

• Avoid combinations of ACE inhibitors and ARBs due to increased risk of adverse events without additional benefit 2

• Avoid combinations of ACE inhibitors or ARBs with direct renin inhibitors 2

Special Population Considerations

• In Black patients, initial treatment should include a diuretic or calcium channel blocker, either alone or in combination with a RAS blocker 1
• For patients with diabetes and albuminuria, an ACE inhibitor or ARB is recommended as first-line therapy 1
• For heart failure with reduced ejection fraction, treatment should include an ACE inhibitor (or ARB), beta-blocker, and diuretic/MRA if required 1
• For chronic kidney disease, target systolic BP of 120-139 mmHg is recommended, with RAS blockers preferred in the presence of albuminuria 1

Lifestyle Modifications

• Sodium restriction to <1500 mg/day or reduction of at least 1000 mg/day 1
• Increased potassium intake (3500-5000 mg/day) 1
• Weight loss if overweight/obese 1
• Physical activity (aerobic or dynamic resistance 90-150 min/week) 1
• Moderation of alcohol intake (≤2 drinks per day in men, ≤1 per day in women) 1
• DASH-like diet rich in fruits, vegetables, whole grains, and low-fat dairy products 1

Monitoring and Follow-up

• Monthly visits until blood pressure target is achieved 1
• For patients treated with ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium levels at least annually 1
• Home BP monitoring or ambulatory BP monitoring to confirm diagnosis and monitor treatment effectiveness 1

Management of Resistant Hypertension

• Resistant hypertension is defined as uncontrolled BP despite ≥3 antihypertensive agents of different classes, including a diuretic, calcium channel blocker, and a RAS blocker 4
• For resistant hypertension, reinforce lifestyle measures, especially sodium restriction 1
• Addition of spironolactone at low dose to existing treatment is recommended for resistant hypertension 1, 5

Target Blood Pressure Goals

• For patients without comorbidities: <140/90 mmHg 2
• For patients with known cardiovascular disease: <130 mmHg systolic 2
• For high-risk patients (high cardiovascular risk, diabetes, chronic kidney disease): <130 mmHg systolic 2