What is the approach to managing a patient with hypertension?

Comprehensive Approach to Managing Hypertension

The management of hypertension requires a combination of lifestyle modifications and pharmacological therapy, with treatment decisions based on blood pressure levels, cardiovascular risk assessment, and patient-specific factors. 1, 2

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 1
• Ambulatory or home blood pressure monitoring is recommended for unusual BP variability, suspected white coat hypertension, or resistant hypertension 1
• Initial evaluation should include urinalysis for blood and protein, blood electrolytes and creatinine, blood glucose and lipid profile, and 12-lead ECG 1
• Formal cardiovascular risk assessment should guide treatment decisions 1

Lifestyle Modifications

• DASH diet rich in fruits, vegetables, whole grains, low-fat dairy products, with reduced saturated and total fat content can lower SBP by 5-8 mmHg 1
• Weight reduction aiming for BMI 20-25 kg/m² provides approximately 1 mmHg SBP reduction per 1 kg weight loss 1
• Sodium restriction to <2,300 mg/day can lower SBP by 2-8 mmHg 1, 3
• Physical activity of 150+ minutes/week of moderate aerobic activity plus resistance training 2-3 times/week lowers SBP by 4-9 mmHg 1
• Alcohol moderation (≤2 drinks/day for men and ≤1 drink/day for women) lowers SBP by 2-4 mmHg 1, 4
• Lifestyle modifications should be tried first for 3-6 months in patients with high-normal BP or grade 1 hypertension without high-risk factors 3

Pharmacological Treatment

Treatment Thresholds

• Immediate treatment is recommended for BP ≥140/90 mmHg regardless of cardiovascular risk 1
• Treatment should be initiated at BP ≥130/80 mmHg for patients with high cardiovascular risk 1

Treatment Strategy

• Combination therapy is recommended as initial treatment for most patients with confirmed hypertension, with preferred combinations including ACE inhibitor or ARB + dihydropyridine calcium channel blocker, or ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1, 2
• Single-pill fixed-dose combinations improve adherence and should be considered 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

Blood Pressure Targets

• For most adults, the target blood pressure is 120-129 mmHg systolic and <80 mmHg diastolic 1
• Lower targets (<130/80 mmHg) are recommended for patients with diabetes, chronic kidney disease, or established cardiovascular disease 1, 4
• For patients with heart failure, target BP should be <130/80 mmHg, with consideration for even lower targets (SBP <120 mmHg) in some patients 4

Patient Adherence Strategies

• Simplify the regimen to once-daily dosing when possible 4
• Incorporate treatment into patient's daily lifestyle 4
• Minimize the cost of therapy and recognize financial barriers 4
• Encourage self-monitoring with validated BP devices 4
• Discuss medication side effects and address patient concerns 4

Special Considerations

Resistant Hypertension

• Evaluate for secondary causes of hypertension 4
• Maximize adherence through simplified regimens and more frequent clinic visits 4
• Weight loss, dietary salt restriction, and moderation of alcohol intake are particularly important 4
• Consider referral to a hypertension specialist 4

Heart Failure with Hypertension

• Diuretics, ACE inhibitors (or ARBs), β-blockers, and aldosterone receptor antagonists are recommended 4
• Avoid non-dihydropyridine CCBs (verapamil, diltiazem), clonidine, and α-blockers 4

Implementation and Follow-up

• Team-based care is the most effective approach for achieving BP control 1
• Monthly follow-up visits until BP target is achieved 1
• Home BP monitoring facilitates medication titration and maintenance of BP goals 1
• Monitor for adverse effects of medications and adjust therapy as needed 5

Benefits of Effective BP Control

• 35-40% reduction in stroke incidence 1
• 20-25% reduction in myocardial infarction 1
• 50% reduction in heart failure 1
• For every 12 mmHg reduction in SBP maintained over 10 years, one death is prevented for every 11 treated patients with additional cardiovascular risk factors 1

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis 5
• Not considering white coat hypertension when office readings are elevated 5
• Inadequate dosing or inappropriate combinations of antihypertensive medications 5
• Not addressing lifestyle modifications alongside pharmacological treatment 5
• Overlooking the need for lower BP targets in high-risk patients 5