What are the recommended treatments for managing hypertension?

Hypertension Management

For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate combination therapy with a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide diuretic, targeting BP <130/80 mmHg, while simultaneously implementing lifestyle modifications including weight loss, sodium restriction, regular aerobic exercise, and alcohol moderation. 1

Diagnosis and Confirmation

• Measure blood pressure using a validated automated device with the patient seated, arm at heart level, taking at least two measurements at each of several visits before confirming the diagnosis 2, 1
• Use ambulatory blood pressure monitoring when clinic readings show unusual variability, suspected white coat hypertension, or apparent treatment resistance 2, 1
• Obtain baseline investigations including urinalysis, electrolytes, creatinine, glucose, lipid panel, and 12-lead ECG 1
• Calculate 10-year cardiovascular disease risk to guide treatment intensity for borderline cases 2, 1

Lifestyle Modifications (Universal First-Line Therapy)

All patients with elevated BP or hypertension require lifestyle interventions, which lower BP and enhance medication efficacy 3, 4:

• Weight reduction: Achieve BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) through reduced calorie and fat intake 2, 1, 3
• Exercise: Perform ≥150 minutes/week of moderate-intensity aerobic activity (brisk walking) or 75 minutes/week vigorous activity, plus resistance training 2-3 times weekly 1, 4
• Sodium restriction: Eliminate table salt, avoid processed foods high in sodium 2, 1, 3
• Alcohol limitation: Men ≤14 units/week, women ≤8 units/week 1, 4
• Dietary pattern: Increase fruits, vegetables, fish, nuts, and unsaturated fats; restrict free sugar to <10% of energy intake 1, 3
• Smoking cessation: Mandatory for cardiovascular risk reduction 1

Pharmacological Treatment Initiation

When to Start Medications

• Immediate initiation: All patients with confirmed BP ≥140/90 mmHg, regardless of cardiovascular risk 1, 5
• Earlier initiation (BP 130-139/80-89 mmHg): Consider after 3 months of lifestyle intervention if high cardiovascular risk persists 1

Initial Drug Therapy Strategy

The modern approach prioritizes combination therapy from the start 1:

• First-line combination: RAS blocker (ACE inhibitor like enalapril or ARB like losartan/candesartan) PLUS either a dihydropyridine calcium channel blocker (amlodipine) OR thiazide/thiazide-like diuretic (chlorthalidone, hydrochlorothiazide) 1, 6, 3
• Use single-pill fixed-dose combinations to improve adherence 1
• For Black patients specifically: Initial therapy should include a diuretic or CCB, either alone or combined with a RAS blocker 1, 5

Important caveat: The 1999 British Hypertension Society guidelines recommended low-dose thiazides or beta-blockers as first-line monotherapy 2, but this has been superseded by current evidence favoring combination therapy and recognizing that beta-blockers are no longer preferred first-line agents 1.

Treatment Escalation

• If BP not controlled with two drugs: Progress to three-drug combination (RAS blocker + CCB + thiazide diuretic) 1, 5
• For resistant hypertension (uncontrolled on three drugs): Add spironolactone as fourth-line agent 1, 5
• Never combine two RAS blockers (ACE inhibitor + ARB together) 1

Blood Pressure Targets

Standard Targets (Most Adults)

• Age <65 years: Systolic 120-129 mmHg, diastolic <80 mmHg 1, 3
• Age ≥65 years: Systolic 130-139 mmHg 1
• Age ≥85 years or symptomatic orthostatic hypotension: Consider more lenient target <140/90 mmHg 1

High-Risk Population Targets

• Diabetes, chronic kidney disease, or established cardiovascular disease: <130/80 mmHg 1, 5
• History of stroke/TIA: Systolic 120-130 mmHg 1
• Chronic kidney disease with eGFR >30: Systolic 120-129 mmHg 1

Minimum Acceptable Control (Audit Standard)

• <150/90 mmHg is the minimum acceptable level when optimal targets cannot be achieved 2

Special Population Considerations

Diabetic Nephropathy

• Losartan specifically indicated for diabetic nephropathy with elevated creatinine and proteinuria (albumin:creatinine ratio ≥300 mg/g) to reduce progression to end-stage renal disease 6
• RAS blockers are first-line when albuminuria/proteinuria present 1

Heart Failure

• HFrEF: Use ACE inhibitor/ARB, beta-blocker, diuretic, and/or mineralocorticoid receptor antagonist 1
• HFpEF: Consider SGLT2 inhibitors 1
• Target: <130/80 mmHg but maintain >120/70 mmHg 5

Coronary Artery Disease

• Target <130/80 mmHg (<140/80 in elderly) 5
• Use RAS blockers and beta-blockers with or without CCBs 5

Left Ventricular Hypertrophy

• Losartan reduces stroke risk in hypertensive patients with LVH, though this benefit does not apply to Black patients 6

Critical Pitfalls to Avoid

• Inadequate confirmation: Failing to obtain multiple measurements across several visits before diagnosing hypertension 1
• Ignoring white coat hypertension: Not using ambulatory monitoring when office readings are disproportionately elevated 1
• Monotherapy initiation: Starting with single agents when combination therapy is now standard for most patients 1
• Underdosing: Using insufficient doses or inappropriate drug combinations 1
• Neglecting lifestyle: Focusing solely on medications without addressing modifiable risk factors 1
• Uniform targets: Not recognizing that high-risk patients (diabetes, CKD, CVD) require lower BP goals 1
• Orthostatic hypotension screening: Forgetting to measure standing BP in elderly and diabetic patients 2

Monitoring Strategy

• Achieve target BP within 3 months of treatment initiation 5
• Use both office and home BP readings for ongoing monitoring 1
• Reassess cardiovascular risk annually 1
• Assess medication adherence objectively when possible 5
• Refer to hypertension specialist if BP remains uncontrolled despite appropriate therapy 5
• Continue BP-lowering treatment lifelong if well tolerated, even beyond age 85 1