What are the recommended management strategies for Hypertension (HTN)?

Management of Hypertension

Hypertension management requires immediate lifestyle modifications for all patients, with pharmacological therapy initiated using combination therapy (preferably a RAS blocker plus calcium channel blocker or thiazide diuretic as a single-pill combination) for confirmed BP ≥140/90 mmHg, targeting <130/80 mmHg in most adults. 1, 2

Diagnosis and Confirmation

• Confirm hypertension using validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms at the first visit 1
• Hypertension is defined as office BP ≥140/90 mmHg, which should be confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 1
• Take at least two measurements per visit over multiple visits before confirming diagnosis, except in severe hypertension or hypertensive emergencies 2
• Assess for target organ damage (left ventricular hypertrophy, proteinuria, retinopathy), cardiovascular risk factors, and secondary causes 1, 2

Lifestyle Modifications (Foundation for All Patients)

All patients with hypertension or prehypertension must receive intensive lifestyle counseling, as these interventions reduce cardiovascular morbidity and mortality even when effects appear modest. 3

Dietary Interventions

• Restrict sodium to 5-6g salt per day (approximately 2,300 mg sodium) by eliminating table salt and avoiding processed foods 1
• Adopt DASH diet (Dietary Approaches to Stop Hypertension) or Mediterranean diet emphasizing vegetables, fruits, and low-fat dairy products 3, 1
• Increase dietary potassium intake through food sources 4

Weight Management

• Achieve and maintain BMI of 20-25 kg/m² and waist circumference <102cm in men, <88cm in women 1
• Weight loss in overweight patients produces clinically significant BP reductions comparable to single-drug therapy 4, 5

Alcohol and Tobacco

• Limit alcohol to ≤20-30g ethanol/day for men and ≤10-20g/day for women (approximately 7 standard drinks per week) 1
• Complete smoking cessation with appropriate support, as smoking risk outweighs BP benefits from medication in mild hypertension 3

Physical Activity

• Engage in at least 30 minutes of moderate dynamic exercise on 5-7 days per week 1
• Regular physical activity reduces BP and provides cardiovascular benefits independent of weight loss 4, 5

Pharmacological Therapy Initiation

Treatment Thresholds

Initiate antihypertensive medications immediately for all patients with confirmed BP ≥140/90 mmHg, regardless of cardiovascular risk. 3, 2

• For BP 140-159/90-99 mmHg in low-moderate risk patients: ESC/ESH recommends 3 months of lifestyle intervention first, but ACC/AHA recommends immediate drug therapy 3
• For high-risk patients (existing CVD, diabetes, CKD, target organ damage): initiate drug therapy immediately at BP ≥140/90 mmHg 3, 2
• For patients >80 years: consider treatment when office SBP ≥160 mmHg 3
• For malignant hypertension or BP >180/110 mmHg: initiate treatment without delay 3, 2

First-Line Drug Selection

Start with combination therapy using a single-pill fixed-dose combination for most patients to improve adherence and achieve BP targets faster. 1

Preferred initial combination: RAS blocker (ACE inhibitor like lisinopril or ARB) PLUS either a dihydropyridine calcium channel blocker (like amlodipine) OR a thiazide/thiazide-like diuretic. 1, 4

• ACE inhibitors (lisinopril) reduce cardiovascular events, stroke, and mortality 6
• Calcium channel blockers (amlodipine) reduce stroke risk and can be used alone or in combination 7
• Thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide) provide robust cardiovascular protection 4, 8

Critical Prescribing Rules

• Never combine two RAS blockers (ACE inhibitor + ARB) as this increases harm without benefit 1
• Use once-daily dosing and fixed-dose combinations to maximize adherence 1
• For black patients: initial therapy should include a calcium channel blocker with either a thiazide diuretic or RAS blocker, as RAS blockers alone are less effective 1

Blood Pressure Targets

Target BP <130/80 mmHg for most adults under 65 years; target SBP <130 mmHg for adults ≥65 years. 1, 2, 4

Risk-Specific Targets

• Diabetes, CKD (eGFR >30), or established CVD: ≤130/80 mmHg 1, 2
• Stroke or TIA history: 120-130 mmHg systolic 1
• General population: 120-129/70-79 mmHg optimal range 1
• When using ambulatory BP monitoring: targets should be approximately 10/5 mmHg lower than office equivalents 2

Monitoring and Titration

• Achieve target BP within 3 months of treatment initiation 1
• Monitor serum creatinine and potassium 2-4 weeks after starting or adjusting ACE inhibitors, ARBs, or aldosterone antagonists 1
• Encourage home BP monitoring to guide medication adjustments and improve control 1, 2
• Reassess cardiovascular risk annually 2

Resistant Hypertension

If BP remains uncontrolled on 3 appropriately dosed medications (including a diuretic), investigate for secondary causes and medication non-adherence before adding a fourth agent. 9

• Consider secondary causes: renal artery stenosis, primary aldosteronism, pheochromocytoma, Cushing's syndrome, obstructive sleep apnea 2, 9
• Red flags for secondary hypertension: sudden onset/worsening, age <30 years, elevated creatinine, hypokalemia, resistant to multiple drugs 2
• Add mineralocorticoid receptor antagonist (spironolactone) as fourth-line agent if no contraindications 9

Special Populations

Elderly Patients (≥65 years)

• Initiate at lower doses and titrate gradually 1
• Monitor carefully for orthostatic hypotension, though asymptomatic orthostatic hypotension should not prevent treatment 1
• Intensive BP control may prevent or arrest cognitive decline 1

Young Adults

• Do not delay treatment despite young age, as early-onset hypertension leads to earlier cardiovascular events 1

Common Pitfalls to Avoid

• Failing to use combination therapy initially: Monotherapy achieves target BP in <50% of patients 1
• Inadequate dosing: Ensure medications are at optimal doses before adding additional agents 9
• Ignoring lifestyle modifications: These enhance medication efficacy and provide independent cardiovascular benefits 3, 4
• Not confirming diagnosis with out-of-office measurements: Prevents overtreatment of white coat hypertension 1, 2
• Using suboptimal diuretics: Chlorthalidone is preferred over hydrochlorothiazide for cardiovascular outcomes 4, 8
• Delaying treatment in high-risk patients: Those with diabetes, CKD, or CVD require immediate intervention at BP ≥140/90 mmHg 2