What are the best methods for managing hypertension?

Managing Hypertension

For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate combination pharmacological therapy with a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide diuretic, preferably as a single-pill combination, while simultaneously implementing lifestyle modifications targeting weight loss, sodium restriction, DASH diet, regular exercise, and alcohol moderation. 1, 2

Initial Diagnosis and Assessment

Confirm the diagnosis properly before committing patients to lifelong therapy:

• Measure BP using validated automated upper arm cuff devices with appropriate cuff size, taking at least two measurements per visit over multiple visits 3, 2
• Confirm diagnosis with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 1, 2
• Measure BP in both arms at first visit; use the higher reading 1
• Check standing BP in elderly patients and those with diabetes to assess for orthostatic hypotension 3

Complete initial workup to identify target organ damage and cardiovascular risk:

• Urinalysis for blood and protein 2
• Serum electrolytes, creatinine, glucose, and lipid profile 2
• 12-lead ECG 2
• Calculate 10-year cardiovascular disease risk 3, 2

Lifestyle Modifications: The Foundation for All Patients

Implement these evidence-based interventions for every hypertensive patient, regardless of whether drug therapy is initiated: 3, 1

Weight Management

• Target BMI 20-25 kg/m² and waist circumference <102 cm (men) or <88 cm (women) 1, 2
• Each 1 kg weight loss reduces systolic BP by approximately 1 mmHg 2

Dietary Interventions

• DASH diet: Emphasize fruits, vegetables, whole grains, low-fat dairy, reduced saturated fat—reduces systolic BP by 5-8 mmHg 3, 2
• Sodium restriction: Limit to <2,300 mg/day (approximately 5-6 g salt)—reduces systolic BP by 2-8 mmHg 3, 1, 2
• Potassium supplementation: Increase dietary potassium intake through fruits and vegetables 3, 1
• Eliminate table salt use 3

Alcohol Moderation

• Men: ≤2 standard drinks per day (maximum 14/week) 3, 1
• Women: ≤1 standard drink per day (maximum 7-9/week) 3, 1
• Include alcohol-free days each week 3
• One standard drink = 14 g pure alcohol (12 oz beer, 5 oz wine, or 1.5 oz spirits) 3

Physical Activity

• Minimum 150 minutes/week of moderate aerobic exercise (30 minutes on 5-7 days/week) 1, 2, 4
• Add resistance training 2-3 times/week 2
• Exercise reduces systolic BP by 4-9 mmHg 2
• Post-exercise hypotension continues up to 24 hours 4

Smoking Cessation

• Mandatory recommendation with appropriate support and assistance 1

Pharmacological Therapy: When and How to Initiate

Treatment Thresholds

Immediate drug therapy is indicated for: 3, 2

• Sustained BP ≥160/100 mmHg regardless of cardiovascular risk 3
• Sustained BP 140-159/90-99 mmHg with any of the following:
  • Target organ damage 3
  • Established cardiovascular disease 3
  • Diabetes 3
  • 10-year cardiovascular disease risk ≥20% 3
• BP ≥130/80 mmHg with high cardiovascular risk 2

For malignant hypertension or hypertensive emergency, initiate treatment immediately without delay. 3

First-Line Combination Therapy

The modern approach prioritizes combination therapy from the start for most patients: 1, 2

Preferred initial combinations: 1, 2

1. ACE inhibitor (e.g., lisinopril) + dihydropyridine calcium channel blocker (e.g., amlodipine) 1, 5, 6
2. ACE inhibitor or ARB + thiazide/thiazide-like diuretic (e.g., chlorthalidone) 1, 7
3. Calcium channel blocker + thiazide/thiazide-like diuretic 1

Use fixed-dose single-pill combinations to improve adherence. 1, 2

Critical Pitfall to Avoid

Never combine two RAS blockers (ACE inhibitor + ARB) as this increases harm without additional benefit. 1

Escalation Strategy

If BP target not achieved with dual therapy: 2

• Progress to triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide/thiazide-like diuretic 2
• Consider adding mineralocorticoid receptor antagonist (e.g., spironolactone) as fourth agent for resistant hypertension 8

Special Population Considerations

Black patients from African descent: 3, 1

• First-line: Thiazide diuretic + calcium channel blocker, OR calcium channel blocker + ARB 3, 1
• ARBs preferred over ACE inhibitors (3-fold lower risk of angioedema) 3
• Annual screening recommended for adults ≥18 years 3
• Emphasize salt restriction and increased potassium intake 3

Elderly patients: 1

• Initiate at lower doses and titrate gradually 1
• Monitor carefully for orthostatic hypotension 1
• Intensive BP control may help prevent cognitive decline 1

Patients with diabetes, CKD, or established CVD: 3, 1

• Lower treatment threshold and targets apply 3, 1

Blood Pressure Targets

Target BP varies by patient characteristics: 3, 1

• Most adults <65 years: 120-129/70-79 mmHg 1
• Adults ≥65 years: Systolic <130 mmHg 1
• Diabetes, CKD, or established CVD: ≤130/80 mmHg 3, 1
• CKD with eGFR >30 mL/min/1.73 m²: 120-129 mmHg systolic 1
• Stroke or TIA history: 120-130 mmHg systolic 1

Note: Home and ambulatory BP readings run approximately 10/5 mmHg lower than office readings; adjust targets accordingly 3

Monitoring and Follow-Up

Structured follow-up is essential for achieving and maintaining control:

• Monthly visits until BP target achieved (goal: within 3 months) 1, 2
• Utilize home BP monitoring to guide medication adjustments 1, 2
• Monitor serum creatinine and potassium 2-4 weeks after initiating or changing doses of ACE inhibitors, ARBs, or aldosterone antagonists 1
• Once controlled, consider 90-day medication refills rather than 30-day to improve adherence 2

Clinical Outcomes: Why This Matters

The evidence for BP control is unequivocal: 7

• Each 10 mmHg reduction in systolic BP decreases cardiovascular events by 20-30% 7
• Effective BP control reduces stroke incidence by 35-40%, myocardial infarction by 20-25%, and heart failure by 50% 2
• For every 12 mmHg systolic BP reduction maintained over 10 years, one death is prevented for every 11 treated patients with additional cardiovascular risk factors 2
• Even a 5 mmHg reduction decreases coronary heart disease mortality by 9%, stroke mortality by 14%, and all-cause mortality by 7% 4

Common Pitfalls and How to Avoid Them

Do not delay treatment in young adults with hypertension—they have earlier onset of cardiovascular events compared to those with normal BP 1

Do not withhold treatment due to asymptomatic orthostatic hypotension—this is not associated with higher rates of cardiovascular events 1

Improve medication adherence through once-daily dosing and fixed-dose combinations rather than blaming patients for "non-compliance" 1

Do not rely solely on office BP measurements for diagnosis or treatment decisions—confirm with home or ambulatory monitoring 1, 2

Team-based care is the most effective approach for achieving BP control, incorporating nurses, pharmacists, and other health professionals with home BP monitoring and telemonitoring 2