What is the initial approach to managing hypertension?

Initial Approach to Managing Hypertension

For patients with newly diagnosed hypertension, begin lifestyle modifications immediately for all patients, and initiate pharmacological therapy with a single agent if BP is 140-159/90-99 mmHg, or with combination therapy (preferably a single-pill combination) if BP is ≥160/100 mmHg. 1, 2

Risk Stratification First

Before initiating treatment, all patients must be stratified by total cardiovascular risk, not just BP level alone, as this determines treatment intensity and urgency. 3 Risk categories include:

• Low added risk: Grade 1 hypertension with 0-2 additional risk factors
• Moderate added risk: Grade 1-2 hypertension with 1-2 risk factors, or Grade 1 with 3+ risk factors
• High added risk: Grade 2 hypertension with 3+ risk factors, metabolic syndrome, or subclinical organ damage
• Very high added risk: Grade 3 hypertension at any risk level, or established cardiovascular/renal disease at any BP level 3

The presence of subclinical organ damage (left ventricular hypertrophy, microalbuminuria, increased arterial stiffness), diabetes, metabolic syndrome, or established cardiovascular disease dramatically escalates risk and mandates more aggressive treatment. 3, 4

Lifestyle Modifications (Universal First Step)

Implement these evidence-based lifestyle changes for all hypertensive patients regardless of medication status:

• Sodium restriction to <1500 mg/day or reduce by at least 1000 mg/day 1, 2
• Increase potassium intake to 3500-5000 mg/day 1, 2
• Weight loss if overweight/obese 1, 2
• Physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise 1, 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy products 1, 2

These interventions have additive effects and enhance pharmacological therapy efficacy. 5

Pharmacological Treatment Initiation

For BP 140-159/90-99 mmHg (Grade 1-2 Hypertension)

Start with monotherapy using one of four first-line drug classes: 1, 2

• Thiazide or thiazide-like diuretics (hydrochlorothiazide, chlorthalidone)
• ACE inhibitors (enalapril, lisinopril)
• Angiotensin receptor blockers (ARBs) (candesartan, losartan)
• Long-acting dihydropyridine calcium channel blockers (amlodipine)

However, if the patient has high or very high cardiovascular risk (diabetes, established CVD, chronic kidney disease, multiple risk factors), initiate combination therapy immediately even at these BP levels. 3, 1

For BP ≥160/100 mmHg (Grade 2-3 Hypertension)

Initiate treatment with two antihypertensive medications from the start, preferably as a single-pill combination to improve adherence. 3, 1, 2 This approach achieves target BP faster and reduces cardiovascular events more rapidly than sequential monotherapy. 3

Preferred two-drug combinations (all well-tolerated and effective): 3, 1, 2

• Thiazide diuretic + ACE inhibitor
• Thiazide diuretic + ARB
• Calcium channel blocker + ACE inhibitor
• Calcium channel blocker + ARB
• Calcium channel blocker + thiazide diuretic

Avoid thiazide + beta-blocker combination in patients with metabolic syndrome or high diabetes risk due to dysmetabolic effects. 3

Special Population Considerations

Patients with Diabetes and Albuminuria

Use ACE inhibitor or ARB as mandatory first-line therapy to provide renal protection. 3, 1

Black Patients

Initial treatment should include a diuretic or calcium channel blocker, either alone or combined with a RAS blocker. 1

Patients with Established Coronary Artery Disease

ACE inhibitors or ARBs are recommended as first-line therapy. 3

Patients with Heart Failure with Reduced Ejection Fraction

Treatment must include ACE inhibitor (or ARB), beta-blocker, and diuretic/mineralocorticoid receptor antagonist if required. 1

Chronic Kidney Disease with Albuminuria

RAS blockers (ACE inhibitor or ARB) are recommended, with target systolic BP of 120-139 mmHg. 1

Target Blood Pressure Goals

• Standard target: <140/90 mmHg for most patients 2
• Intensive target: <130/80 mmHg for patients with established CVD, diabetes, chronic kidney disease, or high cardiovascular risk 3, 1, 2
• Elderly patients (≥65 years): Systolic BP <130 mmHg 5

Monitoring and Follow-Up

• Monthly visits until BP target achieved 1
• Home BP monitoring or ambulatory BP monitoring to confirm diagnosis and monitor treatment effectiveness 1
• Monitor serum creatinine/eGFR and potassium at least annually when using ACE inhibitors, ARBs, or diuretics 3, 1
• Assess for white coat hypertension (one-third of patients with elevated office BP normalize before follow-up) 3

Critical Pitfalls to Avoid

Do not rapidly lower BP in asymptomatic patients in the emergency department - this is unnecessary and potentially harmful. 3 Asymptomatic hypertension without target organ damage rarely requires emergency therapy and patients should be referred for outpatient management with prompt follow-up. 3

Do not use sequential monotherapy as the default approach - this is laborious, frustrating, and delays BP control in high-risk patients who need urgent control. 3 Only 20-30% of patients achieve target BP with monotherapy. 3

Do not ignore medication adherence issues - poor compliance is the most common cause of resistant hypertension. 3 Address cost barriers and side effects proactively. 3

Resistant Hypertension Management

If BP remains ≥140/90 mmHg despite three medications (including a diuretic):

• Reinforce lifestyle measures, especially sodium restriction 1
• Add spironolactone at low dose (25-50 mg/day) as fourth agent 3, 1
• Exclude secondary causes: obstructive sleep apnea, renal artery stenosis, primary aldosteronism, medication non-adherence 3, 6
• Consider ambulatory BP monitoring to exclude white coat effect 3