What is the initial management approach for a patient with hypertension?

Initial Management of Hypertension

For patients with newly diagnosed hypertension, the initial management approach should include lifestyle modifications for all patients, with pharmacological therapy initiated based on blood pressure severity, cardiovascular risk factors, and comorbidities. 1, 2

Diagnosis Confirmation

• Confirm hypertension diagnosis using 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, 2
• For readings ≥130/85 mmHg, confirm with home or ambulatory BP monitoring to rule out white coat hypertension 1

Lifestyle Modifications (First-line 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) 1, 3
• Reduce sodium intake (<2,300 mg/day) and increase potassium intake 2, 4
• Promote weight reduction aiming for BMI 20-25 kg/m² (approximately 1 mmHg SBP reduction per 1 kg weight loss) 1, 2
• Recommend regular physical activity: at least 150 minutes of moderate-intensity aerobic activity per week 2, 5
• Advise alcohol moderation: less than 100g/week of pure alcohol (approximately 7 standard drinks) 2, 6
• Encourage complete smoking cessation 2

Pharmacological Therapy Algorithm

Initial Drug Selection Based on BP Stage:

1. For Stage 1 Hypertension (140-159/90-99 mmHg):

   • In low-risk patients: Start with lifestyle modifications for 3-6 months; if BP remains elevated, initiate drug therapy 1, 2
   • In high-risk patients (with CVD, CKD, diabetes, organ damage): Start drug treatment immediately along with lifestyle modifications 1, 2

2. For Stage 2 Hypertension (≥160/100 mmHg):

   • Initiate pharmacological therapy immediately along with lifestyle modifications 7
   • Consider starting with two-drug combination therapy 7

First-line Medication Choices:

• For non-Black patients: Begin with low-dose ACE inhibitor (like lisinopril 10 mg daily) or ARB 1, 8
• For Black patients: Begin with thiazide-type diuretic or calcium channel blocker 7, 1
• If BP is >20/10 mmHg above goal, consider initiating therapy with two drugs from different classes 7

Medication Combinations and Adjustments

• Preferred first-line combination is a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic 2
• Avoid combining ACE inhibitors with ARBs as this combination is potentially harmful 7, 2
• If BP is not controlled with two-drug combination, increase to a three-drug combination: RAS blocker + CCB + thiazide/thiazide-like diuretic 2
• Consider single-pill combinations to improve adherence 1, 2

Blood Pressure Targets and Monitoring

• Target BP for most adults: <130/80 mmHg 1, 2
• For elderly patients, individualize targets based on frailty 1
• Schedule follow-up visits monthly until BP target is achieved (within 3 months) 1, 2
• Monitor serum creatinine and potassium 2-4 weeks after initiation or dose changes of ACE inhibitors, ARBs, or aldosterone antagonists 2
• Encourage home BP monitoring to guide medication adjustments 1, 2

Common Pitfalls to Avoid

• Delaying treatment in young adults with hypertension, as they have earlier onset of cardiovascular events compared to those with normal BP 2
• Withholding or down-titrating treatment due to asymptomatic orthostatic hypotension 2
• Using inadequate doses or monotherapy in patients with stage 2 hypertension 7
• Combining two RAS blockers (ACE inhibitor and ARB), which can lead to hyperkalemia and acute kidney injury 7, 2
• Neglecting to continue lifestyle modifications after initiating pharmacological therapy 3, 4