What is the recommended treatment for hypertension?

Treatment of Hypertension

For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate combination pharmacological therapy immediately alongside lifestyle modifications, using a RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, targeting a systolic BP of 120-129 mmHg. 1

Blood Pressure Thresholds and Treatment Initiation

Confirmed Hypertension (BP ≥140/90 mmHg)

• Start both lifestyle interventions AND pharmacological therapy immediately, regardless of cardiovascular risk 1
• Do not delay pharmacological treatment while attempting lifestyle modifications alone 1
• Target BP control within 3 months of treatment initiation 1

Elevated BP (120-139/70-89 mmHg) with High CVD Risk

• After 3 months of lifestyle intervention, initiate pharmacological treatment if BP remains ≥130/80 mmHg in patients with:
  • Established CVD, diabetes, chronic kidney disease, or target organ damage 1
  • 10-year CVD risk ≥10% 1

Elevated BP with Low-Medium CVD Risk

• Lifestyle modifications alone are appropriate for those with 10-year CVD risk <10% and no high-risk conditions 1

Blood Pressure Targets

Target systolic BP of 120-129 mmHg in most adults to reduce cardiovascular events, provided treatment is well tolerated. 1

• For patients aged <65 years: Target <130/80 mmHg 2
• For patients aged ≥65 years: Target systolic BP <130 mmHg 2
• For patients with diabetes, CKD, or established CVD: Target <130/80 mmHg 1
• If target of 120-129 mmHg is poorly tolerated, aim for "as low as reasonably achievable" (ALARA principle) 1

First-Line Pharmacological Treatment

Initial Combination Therapy (Preferred for Most Patients)

Start with two-drug combination therapy as initial treatment rather than monotherapy, as this achieves better BP control 1

Preferred combinations: 1

• RAS blocker (ACE inhibitor OR ARB) + dihydropyridine calcium channel blocker
• RAS blocker (ACE inhibitor OR ARB) + thiazide/thiazide-like diuretic

Use fixed-dose single-pill combinations to improve adherence 1

Exceptions to Combination Therapy (Consider Monotherapy)

• Patients aged ≥85 years 1
• Symptomatic orthostatic hypotension 1
• Moderate-to-severe frailty 1
• Low-risk grade 1 hypertension 1

Drug Classes with Proven Cardiovascular Benefit

The following have demonstrated reduction in BP and cardiovascular events: 1

• ACE inhibitors (e.g., lisinopril, enalapril)
• Angiotensin receptor blockers (ARBs) (e.g., candesartan)
• Dihydropyridine calcium channel blockers (e.g., amlodipine)
• Thiazide/thiazide-like diuretics (chlorthalidone and indapamide preferred over hydrochlorothiazide) 1, 2

Special Populations

Black patients: 1

• Initial therapy: ARB + dihydropyridine CCB OR dihydropyridine CCB + thiazide/thiazide-like diuretic
• Avoid ACE inhibitor or ARB monotherapy as first-line

Patients with diabetes and albuminuria: 1

• ACE inhibitor or ARB at maximum tolerated dose is first-line for those with urinary albumin-to-creatinine ratio ≥30 mg/g
• If one class not tolerated, substitute the other 1

Patients with heart failure with reduced ejection fraction: 1

• ACE inhibitor (or ARB if ACE inhibitor not tolerated) or ARNI + beta-blocker + MRA + SGLT2 inhibitor + diuretic as needed 1

Treatment Escalation Algorithm

Step 1: Two-Drug Combination

• RAS blocker + CCB or diuretic 1
• Use fixed-dose single-pill combination 1

Step 2: Three-Drug Combination (if BP not controlled)

• RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1
• Preferably as single-pill combination 1

Step 3: Resistant Hypertension (BP uncontrolled on 3 drugs)

• Add low-dose spironolactone (first choice) 1
• If spironolactone not tolerated or contraindicated: 1
  • Eplerenone, OR
  • Amiloride, OR
  • Higher-dose thiazide/thiazide-like diuretic, OR
  • Beta-blocker (bisoprolol), OR
  • Alpha-blocker (doxazosin)

Important Contraindication

Never combine two RAS blockers (ACE inhibitor + ARB) 1

Lifestyle Modifications

Lifestyle interventions should be initiated concurrently with pharmacological therapy, not sequentially 1

Weight Management

• Achieve and maintain BMI 20-25 kg/m² 1
• Waist circumference <94 cm (men), <80 cm (women) 1

Dietary Modifications

• Sodium restriction: <2,300 mg/day 1
• DASH or Mediterranean diet: 8-10 servings fruits/vegetables per day, 2-3 servings low-fat dairy 1, 2
• Potassium supplementation through diet 2
• Limit free sugar to <10% of energy intake; avoid sugar-sweetened beverages 1

Alcohol Limitation

• Men: ≤2 standard drinks/day (maximum 14/week) 1
• Women: ≤1 standard drink/day (maximum 9/week) 1
• Preferably avoid alcohol entirely for best health outcomes 1

Physical Activity

• Regular aerobic exercise with low-to-moderate intensity dynamic or isometric resistance training 2-3 times/week 1

Tobacco Cessation

• Mandatory: Stop all tobacco use and refer to cessation programs 1

Monitoring and Follow-Up

• Monitor BP every 1-3 months until target achieved 1
• Achieve BP control within 3 months of treatment initiation 1
• For patients on ACE inhibitor, ARB, or diuretic: Monitor serum creatinine/eGFR and potassium at least annually 1
• For patients on spironolactone with ACE inhibitor or ARB: Monitor for hyperkalemia regularly 1
• Maintain treatment lifelong, even beyond age 85 years if well tolerated 1

Common Pitfalls to Avoid

• Do not delay pharmacological therapy in confirmed hypertension (≥140/90 mmHg) while attempting lifestyle modifications alone 1
• Do not start with monotherapy in most patients—combination therapy is more effective 1
• Do not use hydrochlorothiazide when thiazide-like agents (chlorthalidone, indapamide) are available, as they have superior cardiovascular outcomes 1
• Do not combine ACE inhibitor with ARB—this increases adverse events without additional benefit 1
• Do not use beta-blockers as first-line unless compelling indication exists (angina, post-MI, heart failure, rate control) 1
• Exclude pseudoresistance before diagnosing resistant hypertension: poor measurement technique, white coat effect, medication nonadherence, suboptimal drug choices 1