What are the guidelines for managing hypertension (HTN) with medication?

Guidelines for Hypertension Medication Management

Drug treatment should be started in all patients with sustained systolic blood pressure ≥160 mmHg or sustained diastolic blood pressure ≥100 mmHg, and in patients with sustained blood pressure 140-159/90-99 mmHg who have target organ damage, established cardiovascular disease, diabetes, or a 10-year cardiovascular disease risk ≥20%. 1

Thresholds for Initiating Medication

• Start antihypertensive drug treatment immediately in patients with Grade 2 hypertension (≥160/100 mmHg) 1
• For Grade 1 hypertension (140-159/90-99 mmHg), start medication immediately in high-risk patients (with cardiovascular disease, chronic kidney disease, diabetes, organ damage, or aged 50-80 years) 1
• For lower-risk patients with Grade 1 hypertension, start medication if blood pressure remains elevated after 3-6 months of lifestyle interventions 1
• Consider lifestyle modifications for all patients, including weight loss, dietary sodium reduction, physical activity, and limited alcohol consumption 1, 2

Target Blood Pressure Goals

• For most patients, aim for blood pressure <130/80 mmHg 1
• For elderly patients, individualize targets based on frailty status 1, 3
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, aim for a more aggressive target of ≤130/80 mmHg 1
• When using ambulatory or home blood pressure readings, adjust targets accordingly (approximately 10/5 mmHg lower than office readings) 1

Initial Medication Selection

• For non-black patients, start with a low-dose ACE inhibitor (like lisinopril) or ARB (like losartan) 1, 4, 5
• For black patients, start with a low-dose ARB, dihydropyridine calcium channel blocker (like amlodipine), or thiazide/thiazide-like diuretic 1, 3
• Consider specific comorbidities when selecting initial therapy:
  • Heart failure: ACE inhibitor or ARB 3, 5
  • Chronic kidney disease with proteinuria: ACE inhibitor or ARB 4, 5
  • Coronary artery disease: Beta-blocker and ACE inhibitor 6

Combination Therapy Approach

• Most patients will require more than one medication to achieve target blood pressure 7, 2
• Consider initial combination therapy for:
  • Grade 2 or 3 hypertension 1
  • High or very high cardiovascular risk patients 1
• Effective two-drug combinations include:
  • ACE inhibitor or ARB + calcium channel blocker 1, 7
  • ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1, 7
  • Calcium channel blocker + thiazide/thiazide-like diuretic 1
• Never combine an ACE inhibitor with an ARB due to increased adverse effects without additional benefit 7

Medication Titration Algorithm

1. Start with monotherapy or low-dose combination therapy 1
2. If blood pressure remains uncontrolled, increase to full dose of initial medication(s) 1, 8
3. If still uncontrolled, add a third agent from a different class 1
4. For resistant hypertension, consider adding spironolactone or other agents (amiloride, doxazosin, eplerenone, clonidine, or beta-blocker) 1

Monitoring and Follow-up

• Recheck blood pressure within 4 weeks of any medication adjustment 8
• Aim to achieve target blood pressure within 3 months 1, 8
• Consider home blood pressure monitoring to guide therapy 1, 8
• Monitor for medication side effects and adjust therapy accordingly 8

Common Pitfalls and Caveats

• Avoid monotherapy in high-risk patients, as most will require multiple medications 3, 7
• Consider simplifying regimens with once-daily dosing and single-pill combinations to improve adherence 1, 3
• Be cautious with combination of thiazide diuretics and beta-blockers in patients with metabolic syndrome or high diabetes risk 1
• Refer patients with resistant hypertension (uncontrolled on ≥3 medications) to specialists with hypertension expertise 1, 3
• Remember that blood pressure reduction itself, rather than specific drug properties, is largely responsible for cardiovascular benefits 4, 5, 6