What is the recommended treatment for hypertension?

Recommended Treatment for Hypertension

The recommended first-line treatment for hypertension is a combination of lifestyle modifications and pharmacological therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1

Diagnosis and Classification

• Hypertension is diagnosed when office blood pressure readings are consistently ≥140/90 mmHg, with confirmation using home or ambulatory blood pressure monitoring 2
• For most adults, the recommended blood pressure target is 120-129 mmHg systolic, provided treatment is well tolerated 1
• In patients with diabetes, chronic kidney disease, or established cardiovascular disease, a more stringent target of <130/80 mmHg is recommended 1

Lifestyle Modifications

All patients with hypertension or elevated blood pressure should receive advice on lifestyle modifications:

• Weight reduction to achieve ideal body weight through reduced calorie intake 1, 3
• Regular physical activity with predominantly dynamic exercise (e.g., brisk walking) 4
• Dietary sodium restriction (<2,300 mg/day) 1
• Increased consumption of fruits, vegetables (8-10 servings/day), and low-fat dairy products (2-3 servings/day) 1, 5
• Alcohol moderation (≤2 standard drinks/day for men, ≤1 for women) or preferably avoidance 1, 4
• Smoking cessation 1

Pharmacological Treatment

Initial Therapy

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 1
• The preferred combinations are:
  • A RAS blocker (ACE inhibitor like lisinopril 6 or ARB like losartan 7) with a dihydropyridine calcium channel blocker, or
  • A RAS blocker with a thiazide/thiazide-like diuretic 1, 8
• Fixed-dose single-pill combinations are recommended to improve adherence 1, 2

Special Populations

• For black patients, consider starting with an ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic 2
• For patients with diabetic nephropathy, ARBs like losartan are indicated to reduce progression of kidney disease 7
• For patients with heart failure, ACE inhibitors like lisinopril are indicated to reduce symptoms 6
• For patients with left ventricular hypertrophy, losartan is indicated to reduce stroke risk (except in black patients) 7

Treatment Escalation

• If BP is not controlled with a two-drug combination, increase to a three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic) 1
• For resistant hypertension, consider adding a mineralocorticoid receptor antagonist (spironolactone) as fourth-line therapy 1, 2
• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1

Monitoring and Follow-up

• Allow at least four weeks to observe the full response to medication changes 1
• Aim to achieve target BP within 3 months 2
• For patients on ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium at least annually 1
• Maintain BP-lowering drug treatment lifelong, even beyond age 85 if well tolerated 1

Additional Cardiovascular Risk Reduction

• Consider low-dose aspirin (75 mg daily) for secondary prevention or primary prevention in patients >50 years with controlled BP and high cardiovascular risk 1
• Consider statins for patients with hypertension and established cardiovascular disease or high cardiovascular risk 1

Common Pitfalls to Avoid

• Inadequate dosing or insufficient number of medications to reach target BP 8
• Poor medication adherence due to complex regimens (prefer single-pill combinations) 1
• Failure to address lifestyle factors alongside pharmacological treatment 3, 9
• Inappropriate combination of two RAS blockers 1
• Neglecting to monitor for adverse effects, particularly electrolyte abnormalities and renal function changes 1