What are the recommended initial management strategies for hypertensive patients?

Initial Hypertensive Management

For most adults with newly diagnosed hypertension, start with dual combination therapy (RAS blocker + calcium channel blocker OR RAS blocker + thiazide diuretic) as a single-pill combination for BP ≥160/100 mmHg, while those with BP 140-159/90-99 mmHg may start with monotherapy, alongside immediate lifestyle modifications targeting weight, sodium intake, and physical activity. 1, 2

Blood Pressure Confirmation and Targets

Before initiating treatment, confirm the diagnosis with out-of-office monitoring to exclude white coat hypertension: home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg validates office readings of ≥140/90 mmHg. 1, 2

Target BP goals:

• Adults <65 years: 120-129/<80 mmHg 1, 2
• Adults ≥65 years: systolic BP 130-139 mmHg 1, 2
• Patients with diabetes or CKD with albuminuria: 130-139 mmHg systolic 2

Lifestyle Modifications (Foundation for All Patients)

Implement these evidence-based interventions immediately, as they can lower systolic BP by 5-8 mmHg and enhance medication efficacy: 1, 3

• Weight reduction: Target BMI 20-25 kg/m², expecting ~1 mmHg SBP reduction per kg lost 4
• DASH or Mediterranean diet: Emphasize fruits, vegetables, low-fat dairy products 1, 3
• Sodium restriction: Reduce intake to <2,300 mg/day 1, 4
• Potassium supplementation: Increase dietary potassium intake 1
• Physical activity: Regular aerobic exercise 1, 3
• Alcohol moderation: Limit to ≤2 standard drinks/day for men, ≤1 for women 1, 3
• Smoking cessation: For overall CVD risk reduction 1

Initial Pharmacological Treatment Algorithm

For BP 140-159/90-99 mmHg (Stage 1):

Start with monotherapy using one of these first-line agents: 1, 2

• RAS blocker (ACE inhibitor like lisinopril 10 mg daily OR ARB) 2, 5
• Thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) 2, 3
• Calcium channel blocker 2

For BP ≥160/100 mmHg (Stage 2):

Start immediately with dual combination therapy as a single-pill combination: 1, 2, 4

Preferred combinations for non-Black patients:

• RAS blocker (ACE inhibitor or ARB) + calcium channel blocker (first choice) 1, 2
• RAS blocker + thiazide/thiazide-like diuretic (alternative) 1, 2

For Black patients:

• Calcium channel blocker + thiazide diuretic 1, 2
• Calcium channel blocker + RAS blocker (alternative) 1, 2

Single-pill combinations improve adherence and should be prioritized over separate tablets. 2, 4

Special Population Considerations

Diabetes mellitus:

• First-line: ACE inhibitor or ARB 2
• Target BP: 130-139 mmHg systolic for diabetic CKD 2

CKD with albuminuria (UACR ≥30 mg/g):

• Mandatory: ACE inhibitor or ARB as initial therapy 2
• Monitor serum creatinine and potassium 2-4 weeks after initiation 2, 4

Moderate-to-severe CKD (eGFR >30 mL/min/1.73m²):

• Target systolic BP: 120-129 mmHg 2

Titration and Follow-Up

• Reassess BP within 2-4 weeks of initiating therapy 3
• Achieve target BP within 3 months 4
• If BP remains uncontrolled on dual therapy, escalate to triple therapy (RAS blocker + calcium channel blocker + thiazide diuretic) 1

Resistant Hypertension (BP ≥140/90 mmHg on Triple Therapy)

If BP remains elevated despite maximally tolerated doses of three drugs (including a diuretic):

1. Add spironolactone 25-50 mg daily as the fourth agent (most effective option) 1, 2, 4
2. Monitor potassium and creatinine 2-4 weeks after initiation, especially with concurrent RAS blocker use 2, 4
3. If spironolactone is not tolerated, consider: 1
   • Eplerenone (alternative mineralocorticoid receptor antagonist)
   • Beta-blocker (bisoprolol)
   • Alpha-blocker (doxazosin)

Critical Pitfalls to Avoid

• Never combine ACE inhibitor + ARB: This increases adverse effects without additional benefit 2, 4
• Do not use monotherapy for stage 2 hypertension (≥160/100 mmHg): These patients require dual therapy from the start 4
• Do not overlook medication adherence: Non-adherence is a common cause of apparent treatment resistance 2
• Screen for secondary causes before diagnosing resistant hypertension: renal artery stenosis, primary aldosteronism, obstructive sleep apnea, pheochromocytoma 2
• Monitor renal function and electrolytes after initiating RAS blockers, especially in CKD patients 2, 4
• Verify proper BP measurement technique: Use validated automated upper arm cuff with appropriate cuff size, measure both arms 4