Hypertension Treatment
For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate combination therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination, targeting systolic BP of 120-129 mmHg if tolerated. 1
Initial Treatment Strategy
Lifestyle Modifications (All Patients)
- Weight reduction to ideal body weight through caloric restriction 1
- Sodium restriction to <2,300 mg/day 1
- Dietary pattern: 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 1
- Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women (preferably avoid entirely for best outcomes) 1
- Eliminate sugar-sweetened beverages and restrict free sugar to maximum 10% of energy intake 1
- Complete tobacco cessation with referral to smoking cessation programs 1
- Regular physical activity 2
When to Start Pharmacotherapy
Immediate initiation (lifestyle modifications + medications):
- Confirmed BP ≥140/90 mmHg regardless of CVD risk 1
- Confirmed BP ≥130/80 mmHg in patients with high CVD risk (≥10% 10-year risk) after 3 months of lifestyle intervention 1
- BP ≥140/90 mmHg in diabetic patients 1
- BP ≥160/100 mmHg requires prompt initiation of two drugs or single-pill combination 1
Delayed initiation (lifestyle modifications first):
- Elevated BP (120-139/70-89 mmHg) with low/medium CVD risk (<10% over 10 years): lifestyle measures for 3 months, then reassess 1
First-Line Pharmacological Treatment
Standard Patients (Non-Black)
Preferred initial combination (as single-pill if possible): 1
- ACE inhibitor or ARB
- PLUS dihydropyridine calcium channel blocker (CCB)
- OR thiazide/thiazide-like diuretic (chlorthalidone or indapamide preferred)
Black Patients
Initial therapy should include: 1
- Diuretic or CCB, either in combination or with a RAS blocker
- For Sub-Saharan African patients: CCB combined with either thiazide diuretic or RAS blocker 1
Monotherapy Exceptions
Consider starting with single agent in: 1
- Patients aged ≥85 years
- Symptomatic orthostatic hypotension
- Moderate-to-severe frailty
- Elevated BP (120-139/70-89 mmHg) with concomitant indication for treatment
Medication Classes and Evidence
First-line agents (demonstrated CVD event reduction): 1
- ACE inhibitors (e.g., lisinopril) 3
- Angiotensin receptor blockers (ARBs)
- Dihydropyridine calcium channel blockers
- Thiazides and thiazide-like diuretics (chlorthalidone, indapamide)
Beta-blockers: Combine with other major classes when compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, heart rate control) 1
Critical contraindication: Never combine two RAS blockers (ACE inhibitor + ARB) or combine RAS blockers with direct renin inhibitors like aliskiren 1, 4
Treatment Escalation Algorithm
Step 1: Two-Drug Combination
- RAS blocker + CCB or diuretic (preferably single-pill combination) 1
Step 2: Three-Drug Combination (if BP uncontrolled)
- RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1
- Preferably as single-pill combination 1
Step 3: Resistant Hypertension (BP uncontrolled on 3 drugs)
Definition: BP ≥140/90 mmHg despite appropriate lifestyle management plus diuretic and two other antihypertensive drugs at adequate doses 1
Before diagnosing resistant hypertension, exclude: 1
- Medication nonadherence
- White coat hypertension
- Secondary hypertension causes
Treatment approach: 1
- Reinforce lifestyle measures, especially sodium restriction
- Add low-dose spironolactone (first choice) 1
- If spironolactone not tolerated: eplerenone, amiloride, higher-dose thiazide/thiazide-like, or loop diuretic 1
- If still uncontrolled: bisoprolol or doxazosin 1
- Consider renal denervation only at high-volume centers after multidisciplinary assessment and shared decision-making 1
Important monitoring: When adding mineralocorticoid receptor antagonist to ACE inhibitor or ARB, monitor serum creatinine and potassium regularly due to hyperkalemia risk 1
Blood Pressure Targets
Standard Target
120-129 mmHg systolic for most adults if well tolerated 1
Special Populations
Diabetes: <130/80 mmHg 1
Chronic kidney disease (eGFR >30 mL/min/1.73 m²): 120-129 mmHg systolic if tolerated; individualize for lower eGFR or transplant 1
Heart failure with reduced ejection fraction: Use ACE inhibitor or ARB, beta-blocker, diuretic, MRA, and SGLT2 inhibitors 1
Stroke/TIA history: 120-130 mmHg systolic 1
Elderly (≥60 years): <130 mmHg systolic in most; individualized approach for those ≥85 years or with frailty 1
Poorly tolerated treatment: Target systolic BP "as low as reasonably achievable" (ALARA principle) 1
Special Considerations for Specific Conditions
Albuminuria/Proteinuria
- RAS blockers (ACE inhibitor or ARB at maximum tolerated dose) are first-line due to superior albuminuria reduction 1
- Strongly recommended for urinary albumin-to-creatinine ratio ≥300 mg/g 1
- Suggested for ratio 30-299 mg/g 1
Heart Failure with Preserved Ejection Fraction (HFpEF)
- SGLT2 inhibitors recommended for symptomatic patients 1
- ARBs and/or MRAs may be considered to reduce hospitalizations 1
Monitoring and Follow-Up
- Achieve target BP within 3 months 5
- Medication timing: Take at most convenient time to establish routine and improve adherence 1
- Monitor renal function and potassium at least annually when using ACE inhibitor, ARB, or diuretic 1
- Maintain treatment lifelong, even beyond age 85 if well tolerated 1
- Refer to hypertension specialist if BP remains uncontrolled despite appropriate therapy 5
Common Pitfalls to Avoid
- Do not use renal denervation as first-line therapy or in patients with eGFR <40 mL/min/1.73 m² 1
- Do not combine two RAS blockers (increased harm without benefit) 1
- Do not use aliskiren with ACE inhibitors or ARBs (contraindicated combination) 4
- Do not delay treatment in confirmed hypertension ≥140/90 mmHg—initiate promptly 1
- Do not use monotherapy as initial treatment for most patients with confirmed hypertension (combination therapy more effective) 1