How to evaluate and manage hypertension?

Evaluation and Management of Hypertension

Begin with accurate blood pressure measurement using home or ambulatory monitoring to confirm the diagnosis and rule out white coat hypertension, then initiate combination therapy with two first-line agents (ACE inhibitor or ARB plus either a calcium channel blocker or thiazide diuretic) for most patients with confirmed BP ≥140/90 mmHg, targeting <130/80 mmHg. 1, 2

Initial Diagnostic Evaluation

Blood Pressure Confirmation

• Obtain home or ambulatory BP readings to confirm office measurements and exclude white coat hypertension 3, 1
• Use accurate office BP measurement technique as the foundation 2
• Ambulatory monitoring is particularly valuable for identifying masked hypertension 3

Baseline Laboratory Assessment

Perform these specific tests at initial evaluation 3:

• Urine dipstick for blood and protein 3
• Serum electrolytes and creatinine 3
• Blood glucose 3
• Serum total:HDL cholesterol ratio 3
• 12-lead electrocardiogram 3

Risk Stratification

• Calculate 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations to guide treatment intensity 3
• Patients with diabetes or chronic kidney disease are automatically high-risk 3
• Screen for target organ damage (heart, kidneys, blood vessels, eyes) to identify additional treatment candidates 1, 2
• Adults ≥65 years can be assumed to have ≥10% 10-year ASCVD risk 3

Secondary Hypertension Screening

Comprehensive screening for secondary causes is mandatory in adults diagnosed before age 40 (except obese young adults, where obstructive sleep apnea should be evaluated first) 1. Refer to specialists for 3:

• Malignant hypertension or impending complications
• Unusually variable blood pressure
• Suspected underlying causes based on initial evaluation
• Therapeutic failures
• Pregnancy-related hypertension

Lifestyle Modifications

Implement lifestyle interventions in ALL patients regardless of BP level or medication status 2, 4. These modifications reduce BP and enhance medication efficacy 5:

Dietary Interventions (Most Effective)

• Adopt the DASH diet (high in fruits, vegetables, low-fat dairy; low in saturated fat and cholesterol) - this may be the single most effective lifestyle intervention 3, 4
• Restrict sodium to <2g/day 2, 4
• Increase potassium intake to 4700 mg/day through diet (4-5 servings of fruits/vegetables provide 1500-3000 mg) 3
• Increase fruit and vegetable consumption 3

Weight Management

• Achieve and maintain BMI 18.5-24.9 kg/m² and waist circumference <102 cm (men) or <88 cm (women) 6
• Weight reduction shows consistent BP-lowering effects 3, 5

Alcohol Restriction

• Limit to <21 units/week for men and <14 units/week for women 3
• Some guidelines recommend even stricter limits (≤14 drinks/week for men, ≤9 for women) 7, 6

Physical Activity

• Perform 30-60 minutes of aerobic exercise on 4-7 days per week 6
• Emphasize dynamic exercise (brisk walking) over isometric (weight training) 3
• Minimum 150 minutes/week of moderate exercise 2

Other Modifications

• Stop smoking (reduces overall cardiovascular risk) 3, 2
• Consider stress management in selected individuals 6

Common Pitfall: Potassium, calcium, and magnesium supplementation beyond a healthy diet has not shown clinically important BP reduction 7. Focus on dietary sources instead.

Pharmacological Treatment Thresholds

When to Initiate Medication

For BP ≥140/90 mmHg: Start pharmacological treatment immediately along with lifestyle modifications 1, 2

For BP 130-139/80-89 mmHg (Stage 1 Hypertension):

• Initiate medication if 10-year ASCVD risk ≥10%, established CVD, diabetes, or chronic kidney disease 3
• Use lifestyle modifications alone for 3-6 months if ASCVD risk <10% and no target organ damage 1, 4
• If BP remains uncontrolled after lifestyle trial, start medication 4

For BP <130/80 mmHg: Lifestyle modifications only 3

First-Line Medication Regimen

Start with two-drug combination therapy for most patients, preferably as a single-pill combination 1, 2. This approach improves adherence and achieves target BP faster.

Recommended Initial Combinations 1, 2:

1. ACE inhibitor or ARB + dihydropyridine calcium channel blocker (preferably amlodipine) 1, 8, 9
2. ACE inhibitor or ARB + thiazide/thiazide-like diuretic (preferably chlorthalidone or indapamide, NOT hydrochlorothiazide) 3, 5

Critical Pitfall: Never combine two RAS blockers (ACE inhibitor + ARB) 1

Medication Titration Algorithm

If target not reached with two drugs:

• Escalate to triple therapy: ACE inhibitor or ARB + calcium channel blocker + thiazide diuretic 2

For resistant hypertension (uncontrolled on 3 drugs including diuretic):

• Add spironolactone 25-50 mg/day as fourth agent 3, 2
• If spironolactone ineffective or not tolerated, consider eplerenone, beta-blockers, alpha-blockers, or central-acting agents 3
• Maximize diuretic therapy: switch from hydrochlorothiazide to chlorthalidone or indapamide 3
• Use loop diuretics in patients with CKD 3
• Verify medication adherence and rule out white coat effect with home/ambulatory monitoring 3
• Discontinue interfering substances (NSAIDs, stimulants, oral contraceptives) 3
• Refer to hypertension specialist if BP remains uncontrolled 3

Monitoring After Medication Initiation

• Reassess BP every 2-4 weeks until target achieved 2
• Check electrolytes and renal function 2-4 weeks after starting ACE inhibitors, ARBs, or diuretics 3, 2
• Aim to reach target BP within 3 months 2

Blood Pressure Targets

Target BP <130/80 mmHg for most adults 3, 5

More aggressive target of 120-129/<80 mmHg is recommended by European guidelines for most adults, including young adults, if well tolerated 1

For adults ≥65 years:

• Target SBP <130 mmHg for noninstitutionalized, ambulatory, community-dwelling adults 3
• For those with high comorbidity burden and limited life expectancy, use clinical judgment and team-based approach to assess risk-benefit 3
• Monitor carefully for orthostatic hypotension 3

If target cannot be achieved due to poor tolerance, aim for "as low as reasonably achievable" (ALARA principle) 1

Strategies to Optimize Control

Medication Adherence

Up to 25% of patients don't fill their initial prescription, and only 1 in 5 achieves adherence sufficient to match clinical trial benefits 3. Address this by:

• Using once-daily dosing 3
• Prescribing single-pill combination therapy 3
• Actively assessing and addressing non-adherence 3, 2

Team-Based Care

• Implement team-based care approach with nurses, pharmacists, and other health professionals 3
• Use electronic health records and patient registries to identify uncontrolled hypertension 3
• Employ telehealth strategies for monitoring and follow-up 3, 2

Long-Term Management

• Once BP is controlled and stable, follow up yearly for BP and CVD risk factors 1
• Maintain BP-lowering therapy lifelong if well tolerated 1
• Continue home BP monitoring to evaluate treatment effectiveness 2

Special Considerations

Young Adults

• Young adults with hypertension develop CVD events earlier than those with normal BP, supporting early intervention 1
• For those with target organ damage, consider 6-12 months of lifestyle modification before adding medication if BP remains above goal 1

Older Adults

• Careful titration and close monitoring are essential due to comorbidity burden 3
• Assess for orthostatic hypotension 3

Common Pitfall: Failing to confirm diagnosis with out-of-office measurements leads to overtreatment of white coat hypertension and undertreatment of masked hypertension 3, 1.