What is the initial management algorithm for hypertension?

Initial Management Algorithm for Hypertension

For patients with hypertension, the recommended initial management approach is to implement lifestyle modifications alongside pharmacological therapy with a two-drug combination of a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic for most patients with BP ≥140/90 mmHg. 1, 2

Diagnosis and Assessment

• Confirm hypertension diagnosis using validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at first visit and using the arm with higher readings 2
• 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) 2
• Assess for target organ damage, cardiovascular risk factors, and potential secondary causes of hypertension 2

Lifestyle Modifications (for all patients)

• Implement dietary changes following DASH or Mediterranean diet patterns, including reduced sodium intake (<2,300 mg/day), increased potassium intake, and consumption of low-fat dairy products 3, 2
• Encourage regular physical activity with at least 150 minutes of moderate-intensity aerobic activity per week plus resistance training 2-3 times weekly 3, 2
• Recommend weight management with goal of BMI 20-25 kg/m² 2
• Advise alcohol moderation with consumption less than 100g/week of pure alcohol, or preferably complete avoidance 3, 2
• Recommend complete smoking cessation with appropriate supportive care 2

Pharmacological Therapy Algorithm

Step 1: Initial Therapy

• For most patients with BP ≥140/90 mmHg: Start with two-drug combination of RAS blocker (ACE inhibitor or ARB) plus either dihydropyridine CCB or thiazide/thiazide-like diuretic, preferably as a single-pill combination 1, 2
• For low-risk grade 1 hypertension (130/80-139/89 mmHg), patients >80 years, or frail patients: Consider monotherapy 2
• For Black patients: Start with ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic 1, 2

Step 2: If BP Not Controlled After 2-4 Weeks

• Increase to three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1, 2

Step 3: Resistant Hypertension (BP Not Controlled on 3 Drugs)

• Add spironolactone 25 mg daily (if eGFR >50 mL/min/1.73m² and serum potassium ≤5.0 mEq/L) 1, 4
• If spironolactone is not tolerated or contraindicated, consider:
  • Eplerenone 1
  • Higher dose thiazide/thiazide-like diuretic or loop diuretic 1
  • Beta-blocker (e.g., bisoprolol) 1
  • Alpha-blocker (e.g., doxazosin) 1

Specific Drug Dosing

• ACE inhibitors (e.g., lisinopril): Start with 10 mg once daily, usual range 20-40 mg daily 5
• Thiazide diuretics (e.g., hydrochlorothiazide): Start with 12.5-25 mg once daily 6
• Spironolactone (for resistant hypertension): Start with 25 mg once daily 4

BP Targets

• For most adults under 65 years: Target BP <130/80 mmHg 3, 2
• For adults 65-85 years: Target systolic BP 120-129 mmHg if well tolerated 3, 2
• For adults >85 years: Individualize targets based on frailty, with systolic BP 130-139 mmHg if well tolerated 2
• For patients with CKD (eGFR >30 mL/min/1.73m²): Target systolic BP 120-129 mmHg 1

Special Populations

• Patients with diabetes or CKD: Use ACE inhibitor or ARB as part of initial therapy 1, 2
• Patients with heart failure: Include ACE inhibitor or ARB, beta-blocker, and MRA in treatment regimen 1
• Patients with stroke history: Target SBP 120-130 mmHg 1
• Pregnant women: Avoid ACE inhibitors, ARBs, mineralocorticoid receptor antagonists 3

Monitoring and Follow-up

• Monitor BP control with goal of achieving target within 3 months 2
• Check serum creatinine and potassium 7-14 days after initiation or dose changes of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 3, 2
• Consider home BP monitoring to guide medication adjustments 2
• Schedule monthly visits until BP target is achieved 2

Common Pitfalls to Avoid

• Avoid combination of two RAS blockers (ACE inhibitor + ARB) as this can cause harm 2
• Don't delay initiation of drug therapy in patients with BP ≥140/90 mmHg 2
• Don't discontinue BP-lowering treatment in elderly patients if well tolerated, even beyond age 85 2
• Don't overlook the importance of medication adherence - single-pill combinations can improve compliance 2
• Don't forget to assess for secondary causes of hypertension, especially in resistant cases 7