What are the guidelines for initiating hypertension treatment?

Guidelines for Initiating Hypertension Treatment

Blood Pressure Thresholds for Drug Therapy

Initiate antihypertensive drug therapy immediately for all adults with blood pressure ≥140/90 mmHg (Grade 2 hypertension), regardless of cardiovascular risk level. 1, 2

For patients with blood pressure 130-139/80-89 mmHg (Grade 1 hypertension), the decision to start medication depends on cardiovascular risk stratification:

• High or very high cardiovascular risk (established CVD, diabetes with target organ damage, chronic kidney disease, or 10-year ASCVD risk ≥10%): Start drug therapy immediately alongside lifestyle modifications 1, 2

• Moderate cardiovascular risk (10-year ASCVD risk 5-10% or Grade 2 hypertension without other risk factors): Attempt lifestyle modifications for up to 3 months; if blood pressure remains uncontrolled, initiate drug therapy 1

• Low cardiovascular risk (10-year ASCVD risk <5% and Grade 1 hypertension without other risk factors): Lifestyle modifications alone may be delayed for several months, but add drug therapy if blood pressure control is not achieved 1

Initial Pharmacological Approach

Start with two-drug combination therapy as a single-pill combination for most patients requiring medication. 2 This approach is more effective than sequential monotherapy titration and reduces clinical inertia. 2

Drug Selection by Patient Demographics:

For non-Black patients:

• Low-dose ACE inhibitor or ARB + dihydropyridine calcium channel blocker (e.g., lisinopril 10 mg + amlodipine 5 mg) 3, 2, 4

For Black patients:

• Low-dose ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic 3, 2

Critical pitfall: Never combine two renin-angiotensin system blockers (ACE inhibitor + ARB) as this is potentially harmful. 2

Blood Pressure Targets

Target blood pressure is <130/80 mmHg for most adults, including those with diabetes, chronic kidney disease, or established cardiovascular disease. 1, 2, 5

• Initial goal: Reduce blood pressure by at least 20/10 mmHg 3, 2
• Timeline: Achieve target blood pressure within 3 months of initiating treatment 3, 2
• Elderly patients ≥80 years: Target systolic blood pressure <130 mmHg, though some guidelines suggest initiating treatment only when systolic blood pressure ≥160 mmHg 1

Lifestyle Modifications (Essential for All Patients)

Lifestyle interventions must be implemented for all patients with elevated blood pressure, even when drug therapy is initiated. 1, 2, 5 These are complementary to medications, not alternatives. 1

Core lifestyle recommendations:

• Weight management: Achieve and maintain body mass index 18.5-24.9 kg/m² 1, 2
• Dietary pattern: DASH or Mediterranean diet rich in fruits, vegetables, low-fat dairy, and low in saturated fat 1, 2, 5
• Sodium restriction: Reduce intake to <5 g salt (2,000 mg sodium) per day 1, 2
• Potassium supplementation: Increase dietary potassium intake 2, 5
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly plus resistance training 2-3 times per week 2, 5
• Alcohol moderation: Limit to ≤2 standard drinks/day for men, ≤1 drink/day for women 1, 2
• Smoking cessation: Mandatory for cardiovascular disease prevention 1, 2

Monitoring and Follow-Up

Schedule follow-up within 2-4 weeks after initiating or adjusting therapy to assess response and tolerability. 3, 2

• Check serum creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2
• Implement home blood pressure monitoring to track progress and improve medication adherence 3, 2
• If blood pressure remains uncontrolled despite multiple medications, refer to a hypertension specialist 3

Special Considerations

Patients with diuretic use: If the patient is already taking diuretics, start ACE inhibitors at a lower dose (e.g., lisinopril 5 mg once daily) to minimize hypotension risk. 4

Patients with low systolic blood pressure (100-120 mmHg) but requiring treatment: Initiate therapy at lower doses (e.g., lisinopril 2.5 mg) and monitor closely for hypotension. 4

Secondary hypertension screening: Assess for secondary causes in patients with severe hypertension (≥180/110 mmHg), resistant hypertension, or sudden onset in young patients. 3, 6

Promptness matters: Delays in achieving blood pressure control in high-risk hypertensive patients are associated with worse cardiovascular outcomes. 1 Early blood pressure lowering before irreversible organ damage develops is prudent. 1