What is the initial treatment approach for hypertension?

Initial Treatment Approach for Hypertension

Begin with lifestyle modifications for all patients, and initiate pharmacological therapy immediately in high-risk patients (those with CVD, CKD, diabetes, organ damage, or age 50-80 years) while low-to-moderate risk patients should trial lifestyle changes for 3-6 months before starting medications if BP remains elevated. 1

Diagnostic Confirmation

• Confirm hypertension diagnosis using a validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at first visit and using the arm with higher readings 2
• Office BP ≥140/90 mmHg requires confirmation with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 1, 2
• Use the average of multiple readings rather than a single measurement 1

Lifestyle Modifications (First-Line for All Patients)

All patients with hypertension should implement lifestyle changes regardless of whether drug therapy is initiated. 1, 3

• Weight reduction: Achieve and maintain healthy body mass index through caloric restriction for overweight individuals 4, 3
• DASH diet: Adopt Dietary Approaches to Stop Hypertension eating pattern emphasizing fruits, vegetables (8-10 servings/day), low-fat dairy (2-3 servings/day), and reduced saturated fats 4, 5
• Sodium restriction: Limit intake to <2,300 mg/day 4, 3
• Potassium supplementation: Increase through dietary sources (fruits and vegetables) 4, 3
• Alcohol moderation: Limit to ≤2 drinks/day for men, ≤1 drink/day for women 4
• Regular physical activity: At least 150 minutes of moderate-intensity aerobic exercise per week 4, 3
• Smoking cessation: Mandatory for all patients 4

Important caveat: The DASH diet combined with sodium restriction may be the most effective lifestyle intervention, potentially reducing BP by approximately 5 mmHg. 5, 3 These modifications enhance the effectiveness of pharmacological therapy when used concurrently. 1, 3

Pharmacological Therapy Algorithm

When to Start Medications

Immediate drug therapy: 1

• High-risk patients: CVD, CKD, diabetes, organ damage, or age 50-80 years
• BP ≥160/100 mmHg regardless of risk status

Delayed drug therapy (after 3-6 months of lifestyle modification): 1

• Low-to-moderate risk patients with BP 140-159/90-99 mmHg who fail to achieve control with lifestyle changes alone

Initial Drug Selection by Patient Population

For Non-Black Patients: 1, 2

1. Start with low-dose ACE inhibitor or ARB (e.g., lisinopril 10 mg daily or enalapril 5 mg daily) 6, 7
2. Add dihydropyridine calcium channel blocker (DHP-CCB) if monotherapy insufficient
3. Increase to full dose
4. Add thiazide-like diuretic (prefer chlorthalidone over hydrochlorothiazide) 1

For Black Patients: 1, 2

1. Start with low-dose ARB + DHP-CCB combination OR DHP-CCB + thiazide/thiazide-like diuretic
2. Increase to full dose
3. Add diuretic or ACE inhibitor/ARB
4. Add spironolactone if still uncontrolled

For patients with BP ≥150/90 mmHg: Consider initiating with two-drug combination therapy from the start using single-pill combinations to improve adherence. 2, 4

For low-risk grade 1 hypertension, patients >80 years, or frail patients: Monotherapy may be appropriate initially. 1

Special Population Considerations

• Diabetes or CKD: Include ACE inhibitor or ARB as part of initial therapy 2, 4
• Heart failure: Include ACE inhibitor or ARB, beta-blocker, and mineralocorticoid receptor antagonist 2
• Coronary artery disease: Prefer ACE inhibitor or ARB as first-line 4
• Pregnancy or planning pregnancy: Absolutely avoid ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors 2, 4

Blood Pressure Targets

Target BP <130/80 mmHg for most adults under 65 years. 2, 4

• Adults 65-85 years: Target systolic BP 120-129 mmHg if well tolerated 2
• Patients with CKD (eGFR >30 mL/min/1.73m²): Target systolic BP 120-129 mmHg 2
• Elderly patients: Individualize based on frailty status 1
• Minimum goal: Reduce BP by at least 20/10 mmHg 1

Monitoring and Titration

• Achieve target BP within 3 months of initiating therapy 1, 2
• Check serum creatinine and potassium 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2, 4
• Use home BP monitoring for medication titration and maintenance of BP goal 1
• Monthly visits until BP target achieved 1

Common pitfall: Asymptomatic orthostatic hypotension should not be a reason to withdraw or down-titrate treatment, as it is not associated with higher rates of CVD events, syncope, or falls in hypertensive adults. 1

Resistant Hypertension Management

If BP remains ≥130/80 mmHg on ≥3 antihypertensive medications at maximum tolerated doses (or requires ≥4 drugs to control): 1

1. Exclude pseudo-resistance (inaccurate BP measurement, white coat effect, medication non-adherence)
2. Screen for secondary causes of hypertension
3. Add spironolactone as fourth agent (highly effective even without biochemical aldosterone excess) 1, 8
4. If spironolactone contraindicated or not tolerated: Consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1
5. Refer to hypertension specialist if still uncontrolled 1