Hypertension Management
For most adults with hypertension, initial treatment should include a combination of a RAS blocker (ACE inhibitor or ARB) with either a calcium channel blocker or thiazide/thiazide-like diuretic, targeting systolic BP 120-129 mmHg and diastolic BP <80 mmHg. 1
Diagnosis and Assessment
- Diagnosis requires blood pressure measurement using a validated device with the patient seated, arm at heart level, with at least two measurements at each visit 1
- Ambulatory blood pressure monitoring is indicated for unusual BP variability, suspected white coat hypertension, or resistant hypertension 1
- Initial evaluation should include:
Lifestyle Modifications
- All patients with elevated blood pressure or hypertension should implement lifestyle modifications, which can provide substantial benefit and may reduce or eliminate the need for medications 1, 2
- Key lifestyle interventions include:
- Regular aerobic exercise (≥150 min/week moderate intensity or 75 min/week vigorous intensity) plus resistance training (2-3 times/week) 1
- Weight control targeting healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1, 3
- Dietary modifications: increased consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids 1
- Reduced sodium intake (avoid table salt) 1, 2
- Restricted free sugar consumption (maximum 10% of energy intake) 1
- Alcohol restriction: men <14 units/week, women <8 units/week 1, 2
- Smoking cessation 1
Pharmacological Management
- Drug therapy should be initiated promptly in all patients with confirmed BP ≥140/90 mmHg, regardless of cardiovascular risk 1
- For patients with elevated BP (130-139/80-89 mmHg) and high cardiovascular risk, consider drug therapy after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 1
- Initial treatment approach:
- Combination therapy is recommended as initial treatment for most patients with confirmed hypertension 1
- Preferred initial combination: RAS blocker (ACE inhibitor like lisinopril or ARB) with either a dihydropyridine CCB (like amlodipine) or thiazide/thiazide-like diuretic 1, 4, 5
- Single-pill fixed-dose combinations improve adherence 1
- Treatment escalation:
Blood Pressure Targets
- Target systolic BP 120-129 mmHg and diastolic BP <80 mmHg for most adults, provided treatment is well tolerated 1, 6
- Age-specific targets:
- Condition-specific targets:
Special Populations
Chronic Kidney Disease
- Target systolic BP 120-129 mmHg for patients with eGFR >30 mL/min/1.73m² 1
- RAS blockers (like lisinopril) are recommended when albuminuria/proteinuria is present 1, 4
Heart Failure
- For heart failure with reduced ejection fraction (HFrEF): use ACE inhibitor/ARB, beta-blocker, diuretic, and/or mineralocorticoid receptor antagonist 1, 4
- For heart failure with preserved ejection fraction (HFpEF): consider SGLT2 inhibitors 1
Stroke
- Target systolic BP 120-130 mmHg in patients with history of stroke or TIA 1
Ethnic Considerations
- For Black patients: initial therapy should include a diuretic or CCB, either alone or in combination with a RAS blocker 1, 5
Common Pitfalls to Avoid
- Failing to confirm elevated readings with multiple measurements before diagnosis 1
- Not considering white coat hypertension when office readings are elevated 1
- Inadequate dosing or inappropriate combinations of antihypertensive medications 1
- Not addressing lifestyle modifications alongside pharmacological treatment 1, 2, 7
- Overlooking the need for lower BP targets in high-risk patients 1, 6
- Combining two RAS blockers (ACE inhibitor and ARB), which is not recommended 1
Monitoring and Follow-up
- Regular BP monitoring using both office and home readings when possible 1
- Annual reassessment of cardiovascular risk 1
- Lifelong maintenance of BP-lowering treatment if well tolerated, even beyond age 85 1
- Antihypertensive therapy should be titrated according to office and home SBP/DBP levels to achieve appropriate targets 6