What are the step-by-step treatment options for hypertension?

Step-by-Step Treatment of Hypertension

The treatment of hypertension follows a systematic approach starting with lifestyle modifications, followed by medication therapy based on patient characteristics, with the goal of reducing blood pressure to <130/80 mmHg to decrease cardiovascular morbidity and mortality. 1

Diagnosis and Initial Assessment

• Hypertension is defined as persistent office BP ≥140/90 mmHg, particularly if home BP ≥135/85 mmHg or 24h ambulatory BP ≥130/80 mmHg 1
• Use validated automated upper arm cuff device with appropriate cuff size for accurate measurement 1
• At first visit, measure BP in both arms and use the arm with higher readings for subsequent measurements 1
• For BP <130/85 mmHg, remeasure after 3 years; for readings ≥130/85 mmHg, confirm with home or ambulatory BP monitoring 1

Step 1: Lifestyle Modifications

• Implement for all patients with BP ≥140/90 mmHg 1
• Key components include:
  • Weight reduction to maintain healthy body mass index (18.5-24.9 kg/m²) 2
  • Dietary sodium restriction (<100 mmol/day for prevention, 65-100 mmol/day for treatment) 3
  • Regular aerobic exercise (30-60 minutes, 4-7 days per week) 2
  • Limited alcohol consumption (≤14 drinks/week for men, ≤9 drinks/week for women) 2
  • Diet rich in fruits, vegetables, low-fat dairy products, and reduced in saturated fat 2

Step 2: Initiation of Pharmacological Therapy

• For Grade 1 Hypertension (140-159/90-99 mmHg):
  • Start drug treatment immediately in high-risk patients (with CVD, CKD, diabetes, organ damage, or aged 50-80 years) 1
  • For others, reassess after 3-6 months of lifestyle interventions; if BP remains elevated, initiate drug therapy 1
• For Grade 2 Hypertension (≥160/100 mmHg):
  • Start drug treatment immediately in all patients 1

Step 3: First-Line Medication Selection

• For non-Black patients:
  • Start with low-dose ACE inhibitor or ARB 1
  • Examples include lisinopril, which has been shown to reduce cardiovascular events 4
• For Black patients:
  • Start with low-dose ARB plus dihydropyridine calcium channel blocker (DHP-CCB) or DHP-CCB plus thiazide/thiazide-like diuretic 1

Step 4: Medication Titration and Combination Therapy

For non-Black patients:

1. Increase ACE inhibitor/ARB to full dose 1
2. Add DHP-CCB if BP remains above target 1
3. Add thiazide/thiazide-like diuretic (e.g., chlorthalidone) as third agent 1, 5
4. Add spironolactone as fourth agent for resistant hypertension 1

For Black patients:

1. Start with ARB plus DHP-CCB or DHP-CCB plus thiazide/thiazide-like diuretic 1
2. Increase to full doses 1
3. Add diuretic or ACE inhibitor/ARB (whichever wasn't included initially) 1
4. Add spironolactone as fourth agent 1

Step 5: Management of Resistant Hypertension

• If BP remains uncontrolled despite adherence to a regimen with three drugs including a diuretic at optimal doses, consider: 6, 7
  • Spironolactone (preferred fourth-line agent) 6
  • If spironolactone is not tolerated or contraindicated, alternatives include:
    • Amiloride 1, 6
    • Doxazosin 1
    • Eplerenone 1
    • Clonidine 1, 6
    • Beta-blocker 1, 6

Step 6: Monitoring and Target Blood Pressure

• Target BP <130/80 mmHg for most patients; individualize for elderly patients based on frailty 1
• Aim to reduce BP by at least 20/10 mmHg 1
• Monitor to achieve target within 3 months of treatment initiation 1
• If BP remains uncontrolled or other issues arise, refer to a provider with hypertension expertise 1

Special Considerations

• For patients with comorbidities, medication selection should be tailored:
  • Coronary artery disease: RAS blockers, beta-blockers with or without CCBs 1
  • Heart failure: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1
  • Chronic kidney disease: ACE inhibitors or ARBs 1
  • Previous stroke: RAS blockers, CCBs, and diuretics 1
  • Diabetes: ACE inhibitors or ARBs (or thiazides/DHP-CCBs in patients without albuminuria) 1

Common Pitfalls to Avoid

• Not checking medication adherence before adding additional agents 6
• Inadequate dosing of medications before adding new agents 6
• Not allowing sufficient time (2-4 weeks) for full effect of dose adjustments 6
• Overlooking the importance of lifestyle modifications alongside pharmacological therapy 8
• Not considering single-pill combinations to improve adherence 6