What is the treatment algorithm for managing hypertension?

Blood Pressure Treatment Algorithm

First-line therapy for hypertension should include lifestyle modifications plus a combination of a thiazide-type diuretic and either an ACE inhibitor, ARB, or calcium channel blocker for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1, 2

Diagnosis and Classification

• Hypertension is classified as: Normal: <120/80 mmHg, Elevated/Prehypertension: 130-139/80-89 mmHg, Stage 1: 140-159/90-99 mmHg, Stage 2: ≥160/100 mmHg 1
• 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 or home blood pressure monitoring should be considered for suspected white coat hypertension, with expected values approximately 10/5 mmHg lower than office readings 2

Treatment Thresholds

• Initiate antihypertensive drug therapy if sustained systolic blood pressure ≥160 mmHg or sustained diastolic blood pressure ≥100 mmHg 3
• For BP 140-159/90-99 mmHg, consider initiating treatment if cardiovascular disease, target organ damage, diabetes, or estimated 10-year cardiovascular disease risk ≥20% is present 3, 2
• Urgent treatment is needed for BP ≥180/110 mmHg 1

Step 1: Lifestyle Modifications (For All Patients)

• Regular physical activity (≥150 min/week of moderate intensity or 75 min/week of vigorous intensity) 2
• Weight reduction targeting healthy BMI (20-25 kg/m²) 2
• Dietary modifications: increased consumption of vegetables, fruits, low-fat dairy products 2, 4
• Sodium restriction (avoid table salt) 2, 5
• Alcohol moderation (men: <14 units/week, women: <9 units/week) 2, 4
• Smoking cessation 2

Step 2: Initial Pharmacological Therapy

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 3, 2
• Preferred initial combination: RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide/thiazide-like diuretic 2
• Single-pill fixed-dose combinations should be considered to improve adherence 2

Step 3: Adjusting Therapy If BP Not at Goal

• If BP is not controlled with a two-drug combination, progress to a three-drug combination (RAS blocker + CCB + thiazide/thiazide-like diuretic) 2
• For resistant hypertension, add spironolactone as fourth-line therapy 2
• Optimize dosages or add additional drugs until goal blood pressure is achieved 3
• Consider consultation with hypertension specialist if BP remains uncontrolled 3

Blood Pressure Targets

• For most adults under 65 years: <130/80 mmHg 2
• For older patients (≥65 years): 130-139 mmHg systolic 2
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease: <130/80 mmHg 3, 2

Special Populations

Diabetes

• Target BP: <130/80 mmHg 3
• Preferred agents: ACE inhibitor or ARB, plus a CCB or thiazide-like diuretic 3

Chronic Kidney Disease

• Target BP: <130/80 mmHg 3, 2
• Preferred agents: RAS blockers (ACE inhibitor or ARB) when albuminuria/proteinuria is present 2
• Use loop diuretics if eGFR <30 ml/min/1.73m² 3

Heart Failure

• For HFrEF: ACE inhibitor/ARB, beta-blocker, diuretic, and/or mineralocorticoid receptor antagonist 3, 2
• For HFpEF: Consider SGLT2 inhibitors 2

Black Patients

• Initial therapy should include a diuretic or CCB, either alone or in combination with a RAS blocker 2
• ACE inhibitors are less effective as monotherapy in Black patients 6

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
• Combining two RAS blockers (ACE inhibitor and ARB), which is not recommended 2
• Thiazide-induced hypokalemia could contribute to increased ventricular ectopy and possible sudden death, particularly with high doses of thiazides in the absence of a potassium-sparing agent 3

Monitoring and Follow-up

• Regular BP monitoring using both office and home readings when possible 2
• Annual reassessment of cardiovascular risk 2
• Monitor serum electrolytes, creatinine, and blood glucose, especially when using diuretics or RAS blockers 3
• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence 1