What is the best approach for managing hypertension in a multiple-choice question (MCQ) context?

Managing Hypertension: Evidence-Based Approach

For hypertension management in clinical practice, implement a team-based care model with systematic follow-up, initiate lifestyle modifications for BP >120/80 mmHg, and start pharmacological therapy at ≥140/90 mmHg using first-line agents (thiazide diuretics, ACE inhibitors/ARBs, or calcium channel blockers) with a target BP <130/80 mmHg for most adults. 1

Initial Assessment and Risk Stratification

• Confirm diagnosis using proper BP measurement technique and exclude white coat hypertension through home BP monitoring (HBPM) or ambulatory BP monitoring 2
• Assess cardiovascular risk using SCORE2 (ages 40-69) or SCORE2-OP (≥70 years) for 10-year CVD risk calculation to guide treatment intensity 1
• Screen for secondary causes in resistant cases or when clinically indicated (accounts for <10% of hypertension) 3

Lifestyle Modifications (BP >120/80 mmHg)

Initiate immediately for all patients with elevated BP, as these interventions reduce SBP by approximately 5-10 mmHg and enhance medication efficacy 1, 4:

• Dietary changes: DASH eating pattern with sodium restriction <2,300 mg/day, increase potassium intake, consume 8-10 servings fruits/vegetables daily, 2-3 servings low-fat dairy 1
• Weight reduction: Caloric restriction for overweight patients 1
• Physical activity: Regular aerobic exercise 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1

Pharmacological Therapy

When to Start Medication

• Confirmed BP ≥140/90 mmHg: Initiate pharmacotherapy alongside lifestyle modifications 1
• BP 130-139/80-89 mmHg with high CVD risk (10-year ASCVD risk ≥15%): Consider earlier initiation 1

First-Line Drug Selection

Choose from three equally effective classes 4:

1. Thiazide/thiazide-like diuretics: Hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily 4
2. ACE inhibitors: Lisinopril 10 mg daily initially, titrate to 20-40 mg daily (usual range) 5
3. Calcium channel blockers: Amlodipine 5-10 mg daily 4
4. ARBs: Candesartan or telmisartan (alternative to ACE inhibitors) 2, 4

Common pitfall: Beta-blockers like metoprolol are NOT first-line unless compelling indications exist (coronary artery disease, heart failure) 2

Dosing Strategy

• Start with optimal doses of single agents rather than subtherapeutic doses 2
• Use once-daily, long-acting formulations to improve adherence 1
• Consider single-pill combinations when multiple drugs needed 1
• Administer ≥1 antihypertensive at bedtime to reduce cardiovascular events 1

Renal Impairment Adjustments (ACE Inhibitors)

• CrCl >30 mL/min: Standard dose (lisinopril 10 mg daily) 5
• CrCl 10-30 mL/min: Reduce to 5 mg daily 5
• CrCl <10 mL/min (dialysis): Start 2.5 mg daily 5

Blood Pressure Targets

• Adults <65 years: <130/80 mmHg 1
• Adults ≥65 years: SBP <130 mmHg 1
• High CVD risk or 10-year ASCVD ≥15%: Target <130/80 mmHg if safely achievable 1
• Lower risk or high adverse effect risk: <140/90 mmHg acceptable 1

Home BP monitoring target: <135/85 mmHg 2

Team-Based Care Implementation (Class 1 Recommendation)

This approach reduces SBP/DBP and improves BP control rates compared to usual care 1:

• Designate care team members: Pharmacists, nurses, nurse practitioners, physician assistants to manage medication titration under physician supervision 1
• Establish systematic follow-up: 1-month follow-up via telephone, telehealth, or clinic visit after medication initiation 1
• Implement medication titration algorithms led by clinical support team 1
• Monitor adherence using pharmacy fill data 1
• Enable timely patient contact through telephone, secure messaging, or urgent appointments 1

Monitoring and Follow-Up

• Recheck BP within 4 weeks of medication adjustment 2
• Use HBPM systematically for ongoing monitoring (Class 1 recommendation) 1
• Monitor laboratory values: Serum potassium and renal function, especially with ACE inhibitors/ARBs or diuretics 1, 5
• Assess adherence with no-blame approach at each visit 1

Resistant Hypertension (BP >140/90 Despite 3 Drugs)

• Verify true resistance: Confirm with HBPM/ambulatory monitoring, exclude white coat effect 2
• Optimize current regimen: Ensure maximum tolerated doses, must include appropriate diuretic 2
• Add fourth agent - spironolactone 25 mg daily (preferred if K+ <4.5 mmol/L and eGFR >45 mL/min/1.73m²) 2
• Consider switching beta-blocker to dihydropyridine CCB (e.g., amlodipine) if metoprolol is being used 2
• Refer to hypertension specialist if uncontrolled on optimized 4-drug regimen 2

Enhancing Adherence

• Conduct informed CVD risk discussion tailored to patient needs (Class 1 recommendation) 1
• Use motivational interviewing at hospitals and community health centers 1
• Implement physician-patient web communications for reporting home BP readings 1
• Simplify regimens: Once-daily dosing, single-pill combinations, address cost barriers 1
• Assess financial capacity and connect patients with assistance programs 1

Special Populations

Older Adults (≥65 years)

• Use team-based approach to assess risk/benefit with high comorbidity burden and limited life expectancy 1
• Apply clinical judgment regarding treatment intensity 1

Pregnancy

• Avoid ACE inhibitors and ARBs (contraindicated - cause fetal damage) 1
• Safe alternatives: Methyldopa, labetalol, diltiazem, clonidine, prazosin 1
• Avoid chronic diuretics (restrict maternal plasma volume, reduce uteroplacental perfusion) 1

Peri-operative Management

• Continue beta-blockers if already taking 1
• Consider withholding ACE inhibitors/ARBs on day of surgery to reduce intra-operative hypotension risk 1