What are the treatment guidelines for each stage of Hypertension (HTN)?

Treatment Guidelines for Each Stage of Hypertension

For Grade 1 hypertension (140-159/90-99 mmHg), start drug treatment immediately in high-risk patients (CVD, CKD, diabetes, organ damage, or age 50-80 years), while low-risk patients should undergo 3-6 months of lifestyle intervention first; for Grade 2 hypertension (≥160/100 mmHg), initiate pharmacological therapy immediately in all patients. 1, 2

Stage-Specific Treatment Approach

Normal Blood Pressure (<120/80 mmHg)

• Encourage lifestyle modifications and remeasure after 3 years 1

Elevated/Prehypertension (120-139/80-89 mmHg)

• Implement lifestyle modifications including weight loss, dietary sodium reduction (<2g/day), potassium supplementation, physical activity, and alcohol moderation 1, 3, 4
• No pharmacological therapy unless compelling indications exist (heart failure, post-MI, high coronary disease risk, diabetes, CKD, recurrent stroke prevention) 1
• Confirm elevated readings with home BP monitoring (<135/85 mmHg) or 24-hour ambulatory monitoring (<130/80 mmHg) 1, 2

Grade 1 Hypertension (140-159/90-99 mmHg)

High-Risk Patients (CVD, CKD, diabetes, organ damage, or aged 50-80 years):

• Start drug treatment immediately alongside lifestyle modifications 1, 2

Low-Risk Patients:

• Begin with 3-6 months of intensive lifestyle intervention 1, 2
• Initiate pharmacological therapy if BP remains elevated after this period 1, 2

First-Line Drug Selection:

• Non-Black patients: Start with low-dose ACE inhibitor or ARB 1, 2, 3
• Black patients: Start with low-dose ARB plus dihydropyridine calcium channel blocker (DHP-CCB) OR DHP-CCB plus thiazide/thiazide-like diuretic 1, 2
• Consider monotherapy in patients aged >80 years or frail individuals 1

Grade 2 Hypertension (≥160/100 mmHg)

Immediate dual-drug combination therapy is recommended for most patients (use caution in those at risk for orthostatic hypotension): 1

Non-Black Patients - Sequential Add-On Strategy:

1. Low-dose ACE inhibitor/ARB 1, 2
2. Add DHP-CCB 1, 2
3. Increase both to full dose 1, 2
4. Add thiazide/thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) 1, 2, 3, 5
5. Add spironolactone as fourth agent for resistant hypertension 1, 2, 6

Black Patients - Sequential Add-On Strategy:

1. Low-dose ARB plus DHP-CCB OR DHP-CCB plus thiazide/thiazide-like diuretic 1, 2
2. Increase to full dose 1, 2
3. Add the missing component (diuretic or ACE inhibitor/ARB) 1, 2
4. Add spironolactone for resistant hypertension 1, 2

Blood Pressure Targets

Target BP <130/80 mmHg for most patients, with the following modifications: 1, 2, 3

• Patients with CAD: <130/80 mmHg (<140/80 mmHg if elderly) 1
• Patients with previous stroke: <130/80 mmHg (<140/80 mmHg if elderly) 1
• Patients with heart failure: <130/80 mmHg but >120/70 mmHg 1
• Patients with CKD or diabetes: <130/80 mmHg 1, 5
• Elderly patients (≥65 years): SBP <130 mmHg, individualized based on frailty 1, 2, 3
• Patients >80 years: Individualize based on frailty 1, 2

Aim to reduce BP by at least 20/10 mmHg and achieve target within 3 months of treatment initiation. 1, 2

Resistant Hypertension Management

When BP remains uncontrolled on three-drug regimen:

• Spironolactone is the preferred fourth-line agent, effective even without biochemical evidence of aldosterone excess 1, 2, 6
• Alternative fourth-line agents if spironolactone is not tolerated or contraindicated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1, 2, 7
• Before adding agents, verify medication adherence (most common cause of inadequate control) and ensure adequate dosing with sufficient time (2-4 weeks) for full effect 7, 6
• Refer to hypertension specialist if BP remains uncontrolled despite adherence to four-drug regimen including a diuretic 2, 7

Key Implementation Principles

• Use once-daily dosing and single-pill combinations to improve adherence 1, 7
• Thiazide-type diuretics enhance efficacy of multidrug regimens and remain underutilized despite strong evidence 1, 3
• An SBP reduction of 10 mmHg decreases CVD events by approximately 20-30% 3
• Monitor BP control with validated automated upper arm cuff devices using appropriate cuff size 1, 2
• Measure BP in both arms at first visit and use the arm with higher readings for subsequent measurements 1, 2