How should I approach a case of hypertension?

Approaching a Case of Hypertension

Begin with combination therapy (ACE inhibitor or ARB + calcium channel blocker or thiazide diuretic) for most patients with confirmed hypertension (BP ≥140/90 mmHg), targeting <130/80 mmHg, while simultaneously initiating lifestyle modifications. 1

Diagnosis and Confirmation

Confirm the diagnosis before initiating treatment:

• Measure BP using a validated automated upper arm cuff device with appropriate cuff size, with the patient seated and arm at heart level 1
• Take the average of 2+ readings at each visit; if office BP ≥130/85 mmHg, confirm with out-of-office monitoring 1, 2
• Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms hypertension 1, 2
• Measure BP in both arms simultaneously at the first visit; use the arm with higher readings for subsequent measurements 1
• Check standing BP in elderly patients and those with diabetes to assess for orthostatic hypotension 2

Common pitfall: Failing to confirm elevated readings with multiple measurements or out-of-office monitoring leads to overdiagnosis, particularly missing white coat hypertension. 3, 2

Initial Workup

Obtain these tests on every newly diagnosed hypertensive patient:

• Urinalysis for blood and protein 3, 2
• Serum electrolytes, creatinine (calculate eGFR), and glucose 3, 2
• Lipid profile 3, 2
• 12-lead ECG 3, 2
• Formal cardiovascular risk assessment (10-year CVD risk calculation) 1, 2

Screen for secondary hypertension if: resistant hypertension develops, age <30 years with severe hypertension, or sudden onset/worsening of previously controlled BP 2, 4

• Check aldosterone-to-renin ratio in all patients with difficult-to-control or resistant hypertension 2

Treatment Initiation Strategy

For BP ≥140/90 mmHg (Grade 1 or 2 Hypertension):

• Start combination therapy immediately with lifestyle modifications 1
• Do NOT wait 3-6 months for lifestyle changes alone unless the patient is low-risk with Grade 1 hypertension (140-159/90-99 mmHg) AND no high-risk conditions 1

For BP 130-139/80-89 mmHg (Elevated BP):

• Start pharmacological treatment if 10-year CVD risk ≥10%, or if established CVD, diabetes, CKD, familial hypercholesterolemia, or hypertensive organ damage present 1, 2
• Otherwise, initiate lifestyle modifications and reassess in 3-6 months 1

Exception for monotherapy: Consider starting with a single agent only in patients >80 years, frail elderly, or low-risk Grade 1 hypertension 1

Pharmacological Treatment Algorithm

First-line combination therapy (choose one):

For Non-Black Patients: 1

1. Start: Low-dose ACE inhibitor or ARB + dihydropyridine calcium channel blocker (e.g., amlodipine) 1
   • Alternative: ACE inhibitor or ARB + thiazide/thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) 1, 2, 5
2. If inadequate control: Increase to full doses 1
3. If still inadequate: Add thiazide/thiazide-like diuretic (creating 3-drug combination: ACE inhibitor/ARB + CCB + diuretic) 1
4. If still inadequate: Add spironolactone 25-50 mg daily 1
5. If spironolactone not tolerated: Add amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

For Black Patients: 1

1. Start: Low-dose ARB + dihydropyridine CCB, OR dihydropyridine CCB + thiazide/thiazide-like diuretic 1
2. If inadequate control: Increase to full doses 1
3. If still inadequate: Add the missing component (diuretic or ARB/ACE inhibitor) 1
4. If still inadequate: Add spironolactone 1
5. If spironolactone not tolerated: Same alternatives as above 1

Critical point: Use fixed-dose single-pill combinations whenever possible to improve adherence and achieve faster BP control 1, 3, 2

Never combine: Two RAS blockers (ACE inhibitor + ARB) together 1

Special Population Modifications

Coronary Artery Disease: 1

• Use RAS blockers + beta-blockers ± CCB
• Target <130/80 mmHg (<140/80 if elderly)
• Add statin (LDL-C target <55 mg/dL) and aspirin

Heart Failure with Reduced Ejection Fraction: 1

• Use RAS blockers + beta-blockers + mineralocorticoid receptor antagonists
• Consider ARNI (sacubitril-valsartan) instead of ACE inhibitor/ARB
• Target <130/80 mmHg but >120/70 mmHg
• CCBs only if BP remains uncontrolled

Chronic Kidney Disease: 1

• RAS inhibitors are first-line (reduce albuminuria)
• Target <130/80 mmHg (<140/80 if elderly)
• Use loop diuretics if eGFR <30 mL/min/1.73m²
• Monitor eGFR, microalbuminuria, and electrolytes closely

Previous Stroke: 1

• Use RAS blockers, CCBs, and diuretics
• Target <130/80 mmHg (<140/80 if elderly)
• Add statin (LDL-C target <70 mg/dL for ischemic stroke)
• Antiplatelet therapy for ischemic stroke only

COPD: 1

• Use ARB + CCB ± diuretic
• Avoid non-selective beta-blockers; cardioselective beta-blockers acceptable if CAD/HF present
• Smoking cessation is mandatory

Blood Pressure Targets

Standard target for most adults <65 years: <130/80 mmHg 1, 3

For adults ≥65 years: <130 mmHg systolic (individualize based on frailty) 1, 3, 5

For elderly >80 years or frail: <140/80 mmHg 1

For heart failure: <130/80 mmHg but maintain >120/70 mmHg 1

Achieve target within 3 months of treatment initiation 1, 3

Lifestyle Modifications (Initiate Simultaneously with Medications)

Weight reduction: 3, 2, 5

• Target BMI 20-25 kg/m²
• Provides ~1 mmHg SBP reduction per 1 kg weight loss

DASH diet: 3, 2, 5

• Rich in fruits, vegetables, whole grains, low-fat dairy
• Reduced saturated and total fat
• Lowers SBP by 5-8 mmHg

Sodium restriction: 3, 2, 5

• Reduce intake to <2.3 g/day
• Eliminate table salt
• Clinically significant BP reduction in hypertensive patients

Physical activity: 3, 5

• 150+ minutes/week of moderate aerobic activity
• Plus resistance training 2-3 times/week
• Lowers SBP by 4-9 mmHg

Alcohol moderation: 3, 5

• ≤2 drinks/day for men, ≤1 drink/day for women
• Lowers SBP by 2-4 mmHg

Smoking cessation: 1, 3

• Mandatory for all patients, particularly those with COPD or CAD

Follow-up and Monitoring

Follow-up schedule: 1, 3

• Monthly visits until BP target achieved (within 3 months)
• Once controlled, follow-up every 3-6 months

Home BP monitoring: 3, 2

• Encourage self-monitoring with validated devices
• Facilitates medication titration and maintenance of BP goals
• Use telemonitoring when available

Team-based care approach: 3, 2

• Most effective strategy for achieving BP control
• Include multidisciplinary teams, pharmacists, nurses
• Utilize telehealth strategies when appropriate

Resistant Hypertension Management

Definition: BP ≥130/80 mmHg on ≥3 antihypertensive medications at maximum tolerated doses (including a diuretic), or BP controlled but requiring ≥4 drugs 2, 4

Systematic approach: 2, 4

1. Exclude pseudo-resistance (white coat effect, poor adherence, inadequate dosing)
2. Screen for secondary causes (primary aldosteronism, renal artery stenosis, OSA, pheochromocytoma)
3. Identify interfering substances (NSAIDs, decongestants, oral contraceptives, stimulants, licorice)
4. Optimize diuretic therapy (switch to chlorthalidone; use loop diuretics if eGFR <30)
5. Add spironolactone 25-50 mg daily as fourth agent (effective even without aldosterone excess)

Clinical Benefits of BP Control

For every 10 mmHg SBP reduction: 3, 2, 5

• 20-30% reduction in CVD events
• 35-40% reduction in stroke incidence
• 20-25% reduction in myocardial infarction
• 50% reduction in heart failure

For every 12 mmHg SBP reduction maintained over 10 years: One death prevented for every 11 treated patients with additional cardiovascular risk factors 3

Adherence Strategies

Simplify the regimen: 3, 2

• Once-daily dosing whenever possible
• Fixed-dose single-pill combinations preferred

Address barriers: 3

• Minimize cost of therapy
• Recognize and address financial barriers
• Incorporate treatment into patient's daily routine

Monitor adherence: 1

• Check adherence at every visit
• Use home BP monitoring to engage patients