What are the management options for hypertension?

Management of Hypertension

The management of hypertension requires a combination of lifestyle modifications and pharmacological therapy, with initial treatment typically consisting of a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide/thiazide-like diuretic for most patients with confirmed hypertension. 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, 3
• Ambulatory or home blood pressure monitoring is recommended for unusual BP variability, suspected white coat hypertension, or resistant hypertension 4, 1
• Initial evaluation should include urinalysis, blood electrolytes, creatinine, glucose, lipid profile, and 12-lead ECG 3
• Formal cardiovascular risk assessment should guide treatment decisions 4, 3

Lifestyle Modifications

• All patients with hypertension should implement lifestyle modifications, which can lower BP and enhance the efficacy of pharmacological therapy 1, 2
• Weight reduction aiming for BMI 20-25 kg/m² provides approximately 1 mmHg SBP reduction per 1 kg weight loss 1, 2
• DASH diet or Mediterranean diet rich in fruits, vegetables, whole grains, and low-fat dairy products is recommended 1, 2
• Sodium restriction (<2,300 mg/day) and increased potassium intake 1, 2
• Regular physical activity: at least 150 minutes of moderate-intensity aerobic activity per week 1, 2
• Alcohol moderation: less than 7 standard drinks per week 1, 2
• Complete smoking cessation 1, 2

Pharmacological Treatment

Treatment Thresholds

• Immediate treatment is recommended for BP ≥160/100 mmHg regardless of cardiovascular risk 4, 3
• For BP 140-159/90-99 mmHg, treatment is indicated if target organ damage, established cardiovascular disease, diabetes, or 10-year CVD risk ≥15-20% is present 4, 3

Initial Treatment Strategy

• Combination therapy is recommended as initial treatment for most patients with confirmed hypertension 1, 2
• The preferred first-line combination is a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic 1, 2
• Fixed-dose single-pill combinations improve adherence 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this is potentially harmful 1

Treatment Algorithm

1. For stage 1 hypertension (140-159/90-99 mmHg): Start with combination of RAS blocker + CCB or thiazide/thiazide-like diuretic 1, 2
2. For stage 2 hypertension (≥160/100 mmHg): Start with combination of RAS blocker + CCB or thiazide/thiazide-like diuretic 1, 2
3. If BP is not controlled with two-drug combination, increase to a three-drug combination: RAS blocker + CCB + thiazide/thiazide-like diuretic 1
4. For resistant hypertension, consider adding spironolactone as a fourth agent 5, 6

Blood Pressure Targets

• For most adults, the target blood pressure is 120-129/70-79 mmHg 1, 2
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, the target blood pressure is <130/80 mmHg 4, 3, 7
• When using ambulatory BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents 3

Special Considerations

Resistant Hypertension

• Defined as BP ≥130/80 mmHg despite using ≥3 antihypertensive medications of different classes at maximum or maximally tolerated doses 4
• Screen for primary aldosteronism in patients with difficult-to-control or resistant hypertension 4, 1
• Consider adding spironolactone as a fourth-line agent 5, 6

Older Adults

• Intensive BP control in older adults may prevent or partially arrest cognitive decline 4, 1
• Do not withhold or down-titrate treatment due to asymptomatic orthostatic hypotension, as this is not associated with higher rates of cardiovascular events 4, 1

Young Adults

• Do not delay treatment in young adults with hypertension, as they have earlier onset of cardiovascular events compared to those with normal BP 4, 1

Implementation and Follow-up

• Team-based care is the most effective approach for achieving BP control 4, 2
• Monthly follow-up visits until BP target is achieved 2
• Home BP monitoring facilitates medication titration and maintenance of BP goals 4, 1, 2
• Monitor serum creatinine and potassium 2-4 weeks after initiation or dose changes of ACE inhibitors, ARBs, or aldosterone antagonists 1

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis 3, 2
• Not considering white coat hypertension when office readings are elevated 4, 3
• Inadequate dosing or inappropriate combinations of antihypertensive medications 3, 2
• Not addressing lifestyle modifications alongside pharmacological treatment 3, 2
• Overlooking the need for lower BP targets in high-risk patients 3, 2