What are the recommended treatments for managing hypertension?

Management of Hypertension

The recommended first-line treatment for hypertension includes a combination of lifestyle modifications and pharmacological therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1, 2

Diagnosis and Assessment

• Blood pressure should be measured using validated devices with the patient seated, arm at heart level, with at least two measurements at each visit 2
• Hypertension is defined as persistent systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg 1, 3
• Routine investigations should include urine testing, blood electrolytes, creatinine, glucose, cholesterol, and 12-lead ECG 2
• Cardiovascular risk assessment should guide treatment decisions, especially for patients with borderline hypertension 2

Non-Pharmacological Management

Lifestyle Modifications

• Regular aerobic exercise (≥150 min/week of moderate intensity) complemented with resistance training (2-3 times/week) 1, 2
• Weight management targeting healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1, 2
• Adopt Mediterranean or DASH diet rich in fruits, vegetables, low-fat dairy products, and reduced in fat and sodium 1, 4
• Sodium restriction (avoid table salt) and increased potassium intake 2, 5
• Limit alcohol consumption (maximum 100g/week of pure alcohol) 1
• Smoking cessation with supportive care and referral to cessation programs 1
• Restrict free sugar consumption, particularly sugar-sweetened beverages, to a maximum of 10% of energy intake 1

Pharmacological Management

Initial Treatment Approach

• Promptly initiate drug therapy in all patients with confirmed BP ≥140/90 mmHg, regardless of cardiovascular risk 1, 2
• 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, 2
• Combination therapy is recommended as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg) 1, 2

First-Line Medications

• ACE inhibitors (e.g., lisinopril) or ARBs combined with either:
  • Dihydropyridine calcium channel blockers (e.g., amlodipine) or
  • Thiazide/thiazide-like diuretics 1, 2, 3
• Fixed-dose single-pill combinations are preferred to improve adherence 1, 2

Medication Selection Considerations

• ACE inhibitors (e.g., lisinopril) reduce blood pressure and cardiovascular events, with additional benefits for heart failure and post-myocardial infarction patients 6
• Calcium channel blockers (e.g., amlodipine) are effective for hypertension and have additional benefits for angina 7
• Beta-blockers should be used when there are specific indications such as angina, post-myocardial infarction, or heart failure with reduced ejection fraction 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) 1

Treatment Escalation

• If BP is not controlled with a two-drug combination, progress to a three-drug combination (RAS blocker + CCB + thiazide/thiazide-like diuretic) 1, 2
• For resistant hypertension, add spironolactone as fourth-line therapy 2

Blood Pressure Targets

• Target systolic BP 120-129 mmHg for most adults, provided treatment is well tolerated 1, 2
• For older patients (≥65 years), consider targeting systolic BP 130-139 mmHg 2
• For patients ≥85 years or with symptomatic orthostatic hypotension, more lenient targets (<140/90 mmHg) may be appropriate 2
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, target BP <130/80 mmHg 2

Special Populations

Coronary Artery Disease

• Target BP <130/80 mmHg 1
• RAS blockers, beta-blockers with or without CCBs are first-line drugs 1
• Consider lipid-lowering treatment with LDL-C target <55 mg/dL (1.4 mmol/L) 1
• Antiplatelet therapy with aspirin is recommended 1

Stroke

• Target BP <130/80 mmHg (<140/80 in elderly patients) 1
• RAS blockers, CCBs, and diuretics are first-line drugs 1
• Lipid-lowering treatment is mandatory for ischemic stroke 1

Heart Failure

• For HFrEF, use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1, 2
• For HFpEF, consider SGLT2 inhibitors 2
• Target BP <130/80 mmHg but >120/70 mmHg 1

Chronic Kidney Disease

• Target systolic BP 120-129 mmHg for patients with eGFR >30 mL/min/1.73m² 2
• RAS blockers are preferred when albuminuria/proteinuria is present 2

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
• Overlooking lifestyle modifications alongside pharmacological treatment 1, 2
• Combining two RAS blockers (ACE inhibitor and ARB) 1
• Not maintaining lifelong BP-lowering treatment if well tolerated 1