Best Approach for Managing Hypertension
The best approach for managing hypertension combines lifestyle modifications with appropriate pharmacological therapy, starting with a combination of ACE inhibitors/ARBs, calcium channel blockers, and thiazide/thiazide-like diuretics to achieve a target blood pressure of 120-129/80 mmHg for most adults. 1
Diagnosis and Assessment
- Blood pressure should be measured using validated devices with patients seated, arm at heart level, with at least two measurements at each visit 2
- Ambulatory or home blood pressure monitoring is recommended for unusual BP variability, suspected white coat hypertension, or resistant hypertension 1, 2
- Initial evaluation should include:
- Urinalysis for blood and protein
- Blood electrolytes and creatinine
- Blood glucose and lipid profile
- 12-lead ECG 2
- Formal cardiovascular risk assessment should guide treatment decisions 2
Lifestyle Modifications (First-Line for All Patients)
- DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy products, with reduced saturated and total fat content (lowers SBP by 5-8 mmHg) 1
- Weight reduction: Aim for BMI 20-25 kg/m² and healthy waist circumference (<94 cm in men, <80 cm in women); expect approximately 1 mmHg SBP reduction per 1 kg weight loss 1
- Sodium restriction: Limit to <2,300 mg/day (lowers SBP by 2-8 mmHg) 1
- Physical activity: 150+ minutes/week of moderate aerobic activity (30-60 minutes most days) plus resistance training 2-3 times/week (lowers SBP by 4-9 mmHg) 1
- Alcohol moderation: Limit to ≤2 drinks/day for men and ≤1 drink/day for women (lowers SBP by 2-4 mmHg) 1
- Increased potassium intake: Aim for 3,500-5,000 mg/day through dietary sources 1
Pharmacological Treatment
When to Initiate Drug Therapy
- Immediate treatment for:
First-Line Medications
- Combination therapy is recommended for most patients with confirmed hypertension (BP ≥140/90 mmHg) as initial therapy 1
- Preferred first-line combinations:
- Single-pill fixed-dose combinations are preferred to improve adherence 1
- For patients not at target with dual therapy, progress to triple therapy with ACE inhibitor/ARB + calcium channel blocker + thiazide/thiazide-like diuretic 1
Special Considerations
- Diabetes: Target BP <130/80 mmHg 1
- Chronic kidney disease: Target BP <130/80 mmHg 1
- Older adults (≥65 years): Target systolic BP <130 mmHg if well tolerated 5
- Resistant hypertension: Consider screening for primary aldosteronism; add mineralocorticoid receptor antagonist as fourth-line agent 1
Blood Pressure Targets
- General target: 120-129 mmHg systolic and <80 mmHg diastolic for most adults 1
- If treatment is poorly tolerated, aim for "as low as reasonably achievable" (ALARA principle) 1
- Lower targets (<130/80 mmHg) for patients with diabetes, chronic kidney disease, or established cardiovascular disease 1
Implementation Strategies
- Team-based care is the most effective approach for achieving BP control 1
- Home BP monitoring and telemonitoring facilitate medication titration and maintenance of BP goals 1
- Monthly follow-up visits until BP target is achieved 1
- 90-day medication refills rather than 30-day when possible 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 2, 6
- Overlooking the need for lower BP targets in high-risk patients 2
- Not considering secondary causes in resistant hypertension or young patients 1, 2