What are the recommended treatment options for managing hypertension?

Hypertension Management

Initial Treatment Strategy

For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate combination therapy immediately with two first-line agents—preferably a RAS blocker (ACE inhibitor or ARB) combined with either a calcium channel blocker or thiazide/thiazide-like diuretic—as a single-pill combination to improve adherence and achieve target blood pressure. 1, 2

Diagnosis and Confirmation

• Confirm hypertension with multiple measurements using a validated device, with the patient seated and arm at heart level, taking at least two readings per visit 1
• Consider ambulatory blood pressure monitoring for suspected white coat hypertension, unusual BP variability, or resistant hypertension 1
• Perform baseline investigations including urinalysis, serum electrolytes, creatinine, glucose, lipid panel, and 12-lead ECG 1
• Calculate 10-year cardiovascular disease risk to guide treatment intensity for patients with borderline hypertension (130-139/80-89 mmHg) 1

Lifestyle Modifications (Essential for All Patients)

• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Exercise: Minimum 150 minutes/week of moderate-intensity aerobic activity or 75 minutes/week of vigorous activity, plus resistance training 2-3 times weekly 1
• Dietary changes: Adopt a DASH-style diet emphasizing vegetables, fruits, fish, nuts, and unsaturated fatty acids while restricting free sugars to <10% of energy intake 1, 3
• Sodium restriction: Avoid table salt and limit dietary sodium 1
• Alcohol limitation: Men ≤14 units/week, women ≤8 units/week 1
• Smoking cessation: Mandatory for all patients 1

Pharmacological Treatment Algorithm

Step 1: Initial Dual Therapy

• Start with a two-drug combination at low doses: RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic 1, 2
• Use single-pill fixed-dose combinations whenever possible to enhance adherence 1, 2
• The four first-line drug classes are: ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics 2, 3

Step 2: Triple Therapy

• If BP remains uncontrolled after 4 weeks, escalate to triple therapy: RAS blocker + CCB + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1, 2

Step 3: Resistant Hypertension

• For BP uncontrolled on triple therapy, add spironolactone as fourth-line agent 1, 4
• Reassess adherence, screen for secondary causes, and consider specialist referral 2

Blood Pressure Targets

• Adults <65 years: Target systolic BP 120-129 mmHg and diastolic BP <80 mmHg if well tolerated 1
• Adults ≥65 years: Target systolic BP 130-139 mmHg 1
• Adults ≥85 years or with symptomatic orthostatic hypotension: Consider more lenient targets (<140/90 mmHg) 1
• High-risk patients (diabetes, CKD, established CVD): Target <130/80 mmHg 1, 4
• CKD with eGFR >30 mL/min/1.73m²: Target systolic BP 120-129 mmHg 1, 2

Special Population Considerations

Black Patients

• Initial therapy should include a thiazide-like diuretic plus CCB, or CCB plus ARB 4
• Among RAS inhibitors, prefer ARBs over ACE inhibitors due to 3-fold higher risk of angioedema with ACE inhibitors in this population 4
• Single-pill combinations are particularly important given higher rates of resistant hypertension 4

Patients with Coronary Artery Disease

• Target BP <130/80 mmHg (<140/80 in elderly) 4
• Use RAS blockers and beta-blockers as first-line agents, with or without CCBs 4
• Add lipid-lowering therapy targeting LDL-C <55 mg/dL (1.4 mmol/L) 4
• Initiate antiplatelet therapy with aspirin unless contraindicated 4

Patients with Heart Failure

• HFrEF: Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists; consider ARNI (sacubitril-valsartan) as alternative to ACE inhibitor/ARB 4, 1
• HFpEF: Consider SGLT2 inhibitors 1
• Target BP <130/80 mmHg but >120/70 mmHg 4

Patients with Previous Stroke/TIA

• Target systolic BP 120-130 mmHg 1
• Use RAS blockers, CCBs, and diuretics as first-line agents 4
• Add lipid-lowering therapy targeting LDL-C <70 mg/dL (1.8 mmol/L) for ischemic stroke 4
• Antiplatelet therapy for ischemic stroke only; carefully consider in hemorrhagic stroke 4

Patients with Chronic Kidney Disease

• Include RAS blocker when albuminuria/proteinuria is present 1, 4
• Target systolic BP 120-129 mmHg for eGFR >30 mL/min/1.73m² 1

Patients with Diabetes

• Initiate treatment at BP ≥140/90 mmHg 4
• Target BP <130/80 mmHg 4, 1
• RAS blockers are preferred when proteinuria is present 2

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB)—this increases adverse effects without additional benefit 1, 2
• Do not rely on single office readings; confirm diagnosis with multiple measurements and consider ambulatory monitoring 1
• Avoid inadequate dosing or inappropriate drug combinations 1
• Do not neglect lifestyle modifications alongside pharmacological treatment 1
• Avoid delayed treatment intensification when BP remains uncontrolled on current regimen 2
• Do not overlook assessment of medication adherence before adding new agents 2

Enhancing Adherence

• Prescribe single-pill fixed-dose combinations whenever possible 1, 2
• Use once-daily dosing regimens 2
• Implement home blood pressure monitoring for patient feedback 2
• Employ multidisciplinary team approaches involving pharmacists 4, 2
• Use objective methods to assess adherence (pharmacy records, pill counting, electronic monitoring) rather than subjective patient reporting 4

Monitoring and Follow-Up

• Regular BP monitoring using both office and home readings 1
• For patients with hypertensive emergency history, monthly follow-up until target BP achieved and target organ damage regresses 4
• Annual cardiovascular risk reassessment 1
• Continue lifelong BP-lowering treatment if well tolerated, even beyond age 85 1