How to manage a first-time hypertension patient?

Management of First-Time Hypertension Patients

For first-time hypertension patients, implement a structured approach starting with confirming the diagnosis using validated blood pressure measurements, initiating appropriate lifestyle modifications for all patients, and adding pharmacological therapy based on hypertension severity and cardiovascular risk. 1, 2

Diagnosis Confirmation

• Confirm hypertension diagnosis using a validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at first visit 1
• Hypertension is defined as office BP ≥140/90 mmHg, confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 1, 3
• For readings ≥130/85 mmHg, confirm with home or ambulatory BP monitoring to rule out white coat hypertension 1, 2
• At initial evaluation, obtain urinalysis, blood electrolytes, creatinine, glucose, lipid profile, and 12-lead ECG to assess for target organ damage and cardiovascular risk 2

Lifestyle Modifications (For All Patients)

• Implement DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced saturated and total fat content (can lower SBP by 5-8 mmHg) 2, 4
• Recommend weight reduction aiming for BMI 20-25 kg/m² (approximately 1 mmHg SBP reduction per 1 kg weight loss) 2, 5
• Prescribe physical activity of 150+ minutes/week of moderate aerobic activity plus resistance training 2-3 times/week (lowers SBP by 4-9 mmHg) 2, 6
• Advise alcohol moderation (≤2 drinks/day for men and ≤1 drink/day for women) 2, 5
• Recommend sodium restriction (<2,300 mg/day) and increased potassium intake 3, 6

Pharmacological Treatment Algorithm

Grade 1 Hypertension (140-159/90-99 mmHg):

• For high-risk patients (with CVD, CKD, diabetes, organ damage, or aged 50-80 years): Start drug treatment immediately along with lifestyle modifications 1
• For low-moderate risk patients: Start with lifestyle modifications for 3-6 months; if BP remains elevated, initiate drug therapy 1

Grade 2 Hypertension (≥160/100 mmHg):

• Start drug treatment immediately along with lifestyle modifications 1

Initial Drug Selection

For Non-Black Patients:

• Begin with low-dose ACE inhibitor or ARB 1
• If BP target not achieved, increase to full dose 1
• If still not controlled, add a thiazide/thiazide-like diuretic 1, 4

For Black Patients:

• Begin with low-dose ARB + dihydropyridine calcium channel blocker (CCB) or CCB + thiazide/thiazide-like diuretic 1
• If BP target not achieved, increase to full dose 1
• If still not controlled, add diuretic or ACE/ARB 1

Special Considerations

• Consider single-pill combinations to improve adherence 2, 3
• For elderly patients (>80 years) or frail individuals, consider monotherapy and individualize BP targets based on frailty 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this can be harmful 3
• Monitor serum creatinine and potassium 2-4 weeks after initiation or dose changes of ACE inhibitors, ARBs, or aldosterone antagonists 3

Blood Pressure Targets and Follow-up

• Target BP for most adults: <130/80 mmHg 2, 1
• For elderly patients, individualize targets based on frailty 1
• Schedule follow-up visits monthly until BP target is achieved (within 3 months) 2, 3
• Encourage home BP monitoring to guide medication adjustments 2, 3

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 the need for lower BP targets in high-risk patients 2
• Delaying treatment in young adults with hypertension, as they have earlier onset of cardiovascular events 3