How do we control hypertension?

Blood Pressure Control: Comprehensive Management Strategies

Blood pressure control requires a combination of lifestyle modifications and pharmacological therapy, with lifestyle changes being the cornerstone for all patients regardless of hypertension severity. 1

Lifestyle Modifications

Diet

• Follow the DASH diet (Dietary Approaches to Stop Hypertension) rich in fruits, vegetables, whole grains, low-fat dairy products, with reduced saturated and total fat content 1
• Reduce sodium intake to less than 1500 mg/day (optimal goal), with any reduction being beneficial 1
• Increase dietary potassium intake to 3500-5000 mg/day through foods rather than supplements 1
• Moderate alcohol consumption: limit to ≤2 standard drinks/day for men and ≤1 standard drink/day for women 1

Physical Activity

• Engage in regular aerobic exercise 5-7 times/week for 30-60 minutes per session, aiming for at least 150 minutes weekly 1
• Consider dynamic resistance exercise (weight-lifting, circuit training) 2-3 times/week as a supplement to aerobic exercise 1
• Isometric resistance exercises like hand-grip training 3-4 times/week can also be beneficial 1, 2

Weight Management

• Achieve and maintain a healthy body weight; any weight loss is beneficial 1
• Expect approximately 1 mm Hg reduction in systolic blood pressure for every 1 kg weight loss 1

Other Lifestyle Factors

• Smoking cessation is essential as smoking causes acute increases in blood pressure and heart rate 3
• Reduce stress through mindfulness practices or meditation 1, 4
• Limit caffeine intake 4

Pharmacological Therapy

When to Initiate Drug Therapy

• Start immediately in patients with BP ≥160/100 mmHg 1
• Start immediately in high-risk patients (with cardiovascular disease, chronic kidney disease, diabetes, or target organ damage) with BP ≥140/90 mmHg 1
• Consider starting after 3-6 months of lifestyle intervention in low-moderate risk patients with persistent BP elevation of 140-159/90-99 mmHg 1

Medication Selection Algorithm

For non-Black patients:

1. Start with low-dose ACE inhibitor (like lisinopril) or ARB 1, 5
2. Add a dihydropyridine calcium channel blocker (DHP-CCB) 1
3. Increase to full dose 1
4. Add thiazide-like diuretic (preferably chlorthalidone over hydrochlorothiazide) 1, 6
5. Add spironolactone or, if not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

For Black patients:

1. Start with low-dose ARB + DHP-CCB or DHP-CCB + thiazide-like diuretic 1
2. Increase to full dose 1
3. Add diuretic or ACE inhibitor/ARB 1
4. Add spironolactone or alternative agents as above 1

Blood Pressure Targets

• Target BP <130/80 mmHg for most adults 1, 7
• Individualize targets for elderly patients based on frailty 1
• Aim to reduce BP by at least 20/10 mmHg 1

Monitoring and Follow-up

• Schedule monthly visits until blood pressure target is achieved 1
• Use home blood pressure monitoring to guide medication adjustments 1
• Replace 30-day with 90-day prescription refills when possible 1
• Consider telehealth strategies to augment office-based management 1

Special Considerations

• Screen for secondary causes of hypertension in resistant cases (BP uncontrolled on ≥3 drugs) 1
• Evaluate for obstructive sleep apnea, which can contribute to resistant hypertension 1
• Consider team-based care involving nurses, pharmacists, and nutritionists to improve outcomes 1
• Assess for social determinants of health that may affect adherence 1

Common Pitfalls to Avoid

• Failing to confirm office readings with home or ambulatory monitoring, which may lead to overdiagnosis of hypertension 1
• Using hydrochlorothiazide instead of the more effective chlorthalidone 1
• Not allowing adequate time for lifestyle modifications before starting medications in low-risk patients 1
• Poor medication adherence - use fixed-dose combinations when possible to improve compliance 1
• Inadequate follow-up - monthly visits are recommended until target BP is achieved 1