How to manage a case of hypertension?

Management of Hypertension

Begin all patients with lifestyle modifications immediately, and initiate pharmacological therapy with combination treatment (ACE inhibitor or ARB + calcium channel blocker or thiazide diuretic) for most patients with confirmed hypertension, targeting blood pressure <130/80 mmHg. 1, 2, 3

Initial Diagnosis and Confirmation

• Measure blood pressure using validated automated devices with appropriate cuff size, taking at least two readings per visit with the patient seated and arm at heart level 2, 3
• Confirm hypertension diagnosis with multiple office visits showing BP ≥140/90 mmHg, or use home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) to exclude white coat hypertension 2, 3
• For readings ≥130/85 mmHg, confirm with out-of-office monitoring before initiating treatment 1, 3
• Measure standing BP in elderly patients and those with diabetes to assess for orthostatic hypotension 1

Key point: Home BP monitoring is the most practical method for medication titration and is more sensitive than office readings for detecting masked hypertension. 1

Essential Initial Workup

• Urinalysis for blood and protein 2
• Serum electrolytes, creatinine, and glucose 2
• Lipid profile 2
• 12-lead ECG 2
• Formal cardiovascular risk assessment to guide treatment intensity 2
• Screen for primary aldosteronism in all patients with difficult-to-control or resistant hypertension using aldosterone-to-renin ratio 1

Lifestyle Modifications (Mandatory for All Patients)

These interventions have additive effects and enhance medication efficacy: 4

• Weight reduction: Target BMI 20-25 kg/m², providing approximately 1 mmHg SBP reduction per 1 kg weight loss 2, 3
• DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy, with reduced saturated fat—lowers SBP by 5-8 mmHg 2, 3
• Sodium restriction: Eliminate table salt, reduce intake to <2.3 g/day—clinically significant BP reduction in hypertensive patients 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women (maximum 14/week for men, 9/week for women)—lowers SBP by 2-4 mmHg 1, 2, 5
• Physical activity: 150+ minutes/week of moderate aerobic exercise plus resistance training 2-3 times/week—lowers SBP by 4-9 mmHg 1, 2
• Smoking cessation: The cardiovascular risk reduction from stopping smoking outweighs the benefit of treating mild hypertension 1

Pharmacological Treatment Algorithm

When to Start Medications

Immediate drug therapy is indicated for: 2, 3

• BP ≥140/90 mmHg regardless of cardiovascular risk
• BP ≥130/80 mmHg in patients with high cardiovascular risk (CVD, CKD, diabetes, target organ damage, or age 50-80 years)
• Malignant phase hypertension at any age—initiate without delay 1

For low-moderate risk patients with BP 130-139/80-89 mmHg: 3

• Start lifestyle modifications for 3-6 months
• If BP remains elevated, initiate drug therapy

Initial Drug Selection

For non-Black patients: 3, 6, 4

• Start with ACE inhibitor (e.g., lisinopril) or ARB + dihydropyridine calcium channel blocker (e.g., amlodipine), OR
• ACE inhibitor/ARB + thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide)

For Black patients: 3

• Start with ARB + dihydropyridine calcium channel blocker, OR
• Calcium channel blocker + thiazide-like diuretic

Critical practice point: Use fixed-dose combination pills as initial therapy to improve adherence and achieve BP control faster. 1 Never combine ACE inhibitor with ARB—this is harmful. 3

Medication Titration Strategy

• Substitute long-acting chlorthalidone for hydrochlorothiazide when using thiazide diuretics 1
• Use long-acting amlodipine as first-line calcium channel blocker 1
• Schedule monthly visits until BP target is achieved (should occur within 3 months) 1, 2, 3
• Simplify to once-daily dosing whenever possible 2
• Replace 30-day with 90-day refills to improve adherence 1

Blood Pressure Targets

For most adults <65 years: Target <130/80 mmHg 2, 3, 4

For adults ≥65 years: Target SBP <130 mmHg 4

For patients with diabetes, CKD, or established CVD: Target <130/80 mmHg 2, 3

For elderly frail patients: Individualize targets based on frailty; consider monotherapy initially 3

Important caveat: Intensive BP control does not increase orthostatic hypotension risk or hospitalizations, and asymptomatic orthostatic hypotension should not be a reason to withhold or down-titrate treatment. 1

Resistant Hypertension Management

Definition: BP ≥130/80 mmHg on ≥3 antihypertensive medications at maximum tolerated doses (including a diuretic), or BP controlled but requiring ≥4 drugs. 1

Systematic Approach to Resistant Hypertension:

1. Exclude pseudo-resistance: 1

   • Confirm with ambulatory BP monitoring
   • Verify proper cuff size (large arms require large cuffs)
   • Rule out white coat hypertension
   • Assess medication adherence

2. Screen for secondary causes: 1, 7

   • Primary aldosteronism (most common)
   • Renal artery stenosis
   • Obstructive sleep apnea
   • Chronic kidney disease

3. Identify interfering substances: 1

   • Excessive alcohol intake (binge drinking)
   • NSAIDs
   • Decongestants
   • Excessive salt intake

4. Optimize diuretic therapy: 1

   • Volume overload is often the culprit
   • Ensure adequate diuretic dosing

5. Add aldosterone antagonist: 1

   • Spironolactone 25-50 mg/day provides significant additional BP reduction
   • Monitor serum potassium and creatinine closely, especially with concurrent ACE inhibitor/ARB use
   • Alternative: Amiloride has shown good response in randomized trials

6. Refer to hypertension specialist if BP remains uncontrolled 1

Implementation Strategies for BP Control

Team-based care is the most effective approach: 1, 2

• Use multidisciplinary teams including pharmacists, nurses, and community health workers
• Implement telehealth strategies to augment office-based management 1
• Enhance connectivity between patient, provider, and electronic health records 1
• Screen for social determinants of health and financial barriers to medications 1, 2

Home BP monitoring: 1, 2

• Encourage self-monitoring with validated devices
• Use telemonitoring for medication titration
• This facilitates achievement and maintenance of BP goals

Clinical Benefits of BP Control

For every 10 mmHg SBP reduction: 4

• 20-30% reduction in CVD events
• 35-40% reduction in stroke incidence 2
• 20-25% reduction in myocardial infarction 2
• 50% reduction in heart failure 2

For every 12 mmHg SBP reduction maintained over 10 years: One death is prevented for every 11 treated patients with additional cardiovascular risk factors. 2

Additional benefit: Intensive BP lowering may prevent or partially arrest cognitive decline in older adults. 1

Common Pitfalls to Avoid

• Clinical inertia: Failing to intensify therapy when BP remains above target—schedule monthly visits until goal achieved 1
• Inadequate initial therapy: Starting with monotherapy instead of combination treatment in most patients 1, 3
• Wrong diuretic choice: Using hydrochlorothiazide instead of chlorthalidone 1
• Ignoring lifestyle modifications: These enhance medication efficacy and should never be omitted 4
• Premature diagnosis: Not confirming elevated readings with multiple measurements or out-of-office monitoring 2, 3
• Overlooking secondary causes: Especially in resistant hypertension—always screen for primary aldosteronism 1
• Inappropriate BP targets: Not using lower targets (<130/80 mmHg) in high-risk patients 2, 3