What is the initial management for hypertensive vascular disease?

Initial Management of Hypertensive Vascular Disease

The initial management of hypertensive vascular disease should include lifestyle modifications for all patients, with pharmacological therapy added based on blood pressure level and cardiovascular risk assessment. 1, 2, 3

Lifestyle Modifications (First-Line for All Patients)

• Weight reduction for overweight individuals through caloric restriction is recommended for all patients with blood pressure >120/80 mmHg 3
• Adopt a DASH (Dietary Approaches to Stop Hypertension) eating pattern with increased fruits, vegetables, and low-fat dairy products 3
• Sodium restriction (<2,300 mg/day) for all patients with elevated blood pressure 3
• Regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) 3
• Moderation of alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) 3
• Smoking cessation for all patients 3
• Increased potassium intake through fruits and vegetables (8-10 servings/day) 3

Pharmacological Therapy Algorithm

Initial Drug Selection Based on BP Level and Risk:

• Stage 1 Hypertension (130-139/80-89 mmHg):

  • With 10-year ASCVD risk <10%: Begin with lifestyle modifications alone and reassess in 3-6 months 1
  • With 10-year ASCVD risk ≥10%: Combine lifestyle modifications with single antihypertensive drug and reassess in 1 month 1

• Stage 2 Hypertension (≥140/90 mmHg):

  • Initiate combination of lifestyle modifications and two antihypertensive drugs from different classes, preferably a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide/thiazide-like diuretic 1, 2
  • Reassess in 1 month 1

• Very High BP (≥180/110 mmHg):

  • Prompt evaluation and immediate antihypertensive drug treatment with close follow-up within 1 week 1

First-Line Medication Options:

• ACE inhibitors (e.g., lisinopril starting at 10 mg daily, titrate to 20-40 mg) 4, 5
• ARBs (e.g., losartan starting at 50 mg daily, titrate to 100 mg as needed) 6, 5
• Thiazide or thiazide-like diuretics 5
• Calcium channel blockers 5

Special Population Considerations

• Black patients: Consider starting with ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic 2
• Patients with diabetes or CKD: Include ACE inhibitor or ARB as part of initial therapy 2
• Patients with metabolic syndrome: Consider ACE inhibitors or ARBs as first-line agents, as they are associated with lower incidence of new-onset diabetes 1
• Elderly patients (65-85 years): Target systolic BP 120-129 mmHg if well tolerated 2

Blood Pressure Targets

• For most adults under 65 years: <130/80 mmHg 2
• For adults 65-85 years: systolic BP 120-129 mmHg if well tolerated 2
• For patients with CKD: systolic BP 120-129 mmHg 2

Monitoring and Follow-up

• For patients on lifestyle modifications alone: Reassess in 3-6 months 1
• For patients on pharmacological therapy: Reassess in 1 month 1
• Check serum creatinine and potassium 7-14 days after initiation or dose changes of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2
• Aim to achieve BP target within 3 months 2

Common Pitfalls and Caveats

• Inadequate dosing or insufficient number of medications is a common cause of treatment failure 1
• Non-adherence to lifestyle modifications often necessitates earlier pharmacological intervention 1
• Patients with resistant hypertension (BP not controlled despite ≥3 drugs including a diuretic) require more extensive evaluation for secondary causes 1
• White coat hypertension should be ruled out with home or ambulatory BP monitoring before intensifying therapy 1
• Single-pill combinations improve medication adherence and should be considered when multiple agents are required 3