What is the recommended guideline for a first-time hypertensive patient's maintenance?

Guidelines for First-Time Hypertension Maintenance

For first-time hypertensive patients, initial treatment should include a combination of lifestyle modifications and pharmacological therapy with a RAS blocker (ACE inhibitor or ARB) plus a dihydropyridine calcium channel blocker or thiazide-like diuretic, preferably as a single-pill combination. 1

Diagnosis and Assessment

• Hypertension is diagnosed when office blood pressure readings are consistently ≥140/90 mmHg, particularly if confirmed by home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 1
• Use a validated automated device with appropriate cuff size for accurate measurement 1
• Take multiple readings (at least 2-3) during each visit and average them for greater accuracy 1

Treatment Approach

Lifestyle Modifications (for all hypertensive patients)

• Sodium restriction to <1500 mg/day or reduction of at least 1000 mg/day 1
• Increased dietary potassium intake (3500-5000 mg/day) 1
• Weight loss if overweight/obese (target ideal body weight or at least 1 kg reduction) 1
• Regular physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise, or 3 sessions/week of isometric resistance training 1
• Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women, or preferably less than 100g/week of pure alcohol) 1
• Adoption of a DASH-like or Mediterranean diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced saturated and total fat 1
• Smoking cessation with referral to supportive programs 1

Pharmacological Therapy

Initial Drug Selection

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 1
• Preferred first-line combinations:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker 1
  • RAS blocker (ACE inhibitor or ARB) + thiazide/thiazide-like diuretic 1
• For non-Black patients: Start with low-dose ACE inhibitor/ARB (e.g., lisinopril 10 mg daily) 1, 2
• For Black patients: Start with low-dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 1
• Single-pill combinations are preferred to improve adherence 1

Special Considerations

• For elderly patients (>80 years) or frail individuals, consider starting with monotherapy 1
• For patients with specific comorbidities, certain drug classes are preferred:
  • Heart failure: ACEI/ARB, beta-blockers, diuretics 1
  • Diabetes with albuminuria: ACEI/ARB 1
  • Chronic kidney disease: ACEI/ARB 1

Blood Pressure Targets

• For most adults: Target systolic BP of 120-129 mmHg 1
• For patients with diabetes, renal impairment, or established cardiovascular disease: Target BP ≤130/80 mmHg 1
• If treatment is poorly tolerated, aim for "as low as reasonably achievable" (ALARA principle) 1

Monitoring and Follow-up

• For patients initiating drug therapy: Follow up approximately monthly for dose titration until BP is controlled 1
• Once BP is controlled: Follow up every 3-6 months 1
• Home BP monitoring is recommended to assess control and improve adherence 3
• If BP remains uncontrolled despite a three-drug regimen (RAS blocker + CCB + diuretic), consider adding spironolactone or other fourth-line agents 1

Common Pitfalls to Avoid

• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this increases adverse effects without additional benefit 1
• Avoid delaying pharmacological treatment in patients with Grade 2 hypertension (≥160/100 mmHg) as immediate drug treatment is recommended 1
• Avoid discontinuing treatment once BP is controlled, as lifelong therapy is typically required 1
• Avoid inadequate dosing - titrate medications to achieve target BP within 3 months 1

By following these guidelines, most first-time hypertensive patients can achieve adequate blood pressure control, reducing their risk of cardiovascular events and mortality.