What are the recommended treatments for managing hypertension?

Hypertension Management

For most adults with confirmed hypertension (BP ≥140/90 mmHg), immediately initiate combination pharmacological therapy with two first-line agents—preferably a RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic—as a single-pill combination, alongside comprehensive lifestyle modifications. 1, 2

Diagnosis and Confirmation

• Measure blood pressure using a validated device with the patient seated, arm at heart level, taking at least two measurements per visit across multiple visits to confirm diagnosis 1, 3
• Check standing blood pressure in elderly and diabetic patients to exclude orthostatic hypotension 1
• Consider ambulatory blood pressure monitoring when clinic readings show unusual variability, suspected white coat hypertension, or apparent treatment resistance 1, 3
• Calculate 10-year cardiovascular disease risk to guide treatment intensity, particularly for patients with borderline hypertension (systolic 130-139 mmHg or diastolic 80-89 mmHg) 1, 2, 3

Lifestyle Modifications (Essential for All Patients)

Weight and Body Composition:

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1, 2

Physical Activity:

• Perform ≥150 minutes/week of moderate-intensity aerobic exercise (or 75 minutes/week vigorous intensity) 1, 3, 4
• Add low- to moderate-intensity resistance training 2-3 times weekly 1, 2

Dietary Modifications:

• Adopt Mediterranean or DASH dietary patterns emphasizing fruits, vegetables, fish, nuts, and unsaturated fatty acids 1, 3
• Restrict sodium intake by avoiding table salt and eliminating excessively salty processed foods 1, 4
• Limit free sugar consumption to maximum 10% of energy intake; avoid sugar-sweetened beverages 1, 3

Alcohol and Tobacco:

• Limit alcohol to <100 g/week of pure alcohol (preferably avoid entirely for best outcomes) 1, 3
• Stop all tobacco use immediately and refer to cessation programs 1, 3

Pharmacological Treatment Algorithm

Initial Therapy (BP ≥140/90 mmHg):

• Start combination therapy immediately with two drugs: RAS blocker (ACE inhibitor or ARB) PLUS either a dihydropyridine calcium channel blocker OR thiazide/thiazide-like diuretic (chlorthalidone or indapamide preferred) 1, 2, 3
• Prescribe as single-pill fixed-dose combination to improve adherence 1, 2, 3
• Exception: Consider monotherapy for patients ≥85 years, those with symptomatic orthostatic hypotension, moderate-to-severe frailty, or elevated BP (systolic 120-139 mmHg) with specific indications 1

Escalation if Uncontrolled After 4 Weeks:

• Progress to triple therapy: RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 1, 2, 3

Resistant Hypertension (Uncontrolled on Triple Therapy):

• Add spironolactone as fourth-line agent 3

First-Line Drug Classes with Proven CVD Event Reduction:

• ACE inhibitors 1, 4
• ARBs 1, 5, 4
• Dihydropyridine calcium channel blockers 1, 4
• Thiazide/thiazide-like diuretics (chlorthalidone, indapamide, hydrochlorothiazide) 1, 4

Beta-Blockers:

• Reserve for compelling indications: angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control 1

Blood Pressure Targets

Most Adults (<65 years):

• Target systolic BP 120-129 mmHg and diastolic <80 mmHg if well tolerated 1, 2, 3

Older Adults (≥65 years):

• Target systolic BP 130-139 mmHg 2, 3

High-Risk Patients (diabetes, CKD, established CVD):

• Target <130/80 mmHg 2, 3, 4

Patients ≥85 Years or with Symptomatic Orthostatic Hypotension:

• Consider more lenient targets (<140/90 mmHg) 3

If Targets Not Tolerated:

• Apply "as low as reasonably achievable" (ALARA) principle 1

Special Population Considerations

Black Patients:

• Initial therapy should include thiazide-like diuretic plus calcium channel blocker, or calcium channel blocker plus ARB 2, 3

Diabetes:

• Initiate treatment at BP ≥140/90 mmHg; target <130/80 mmHg 2, 3

Chronic Kidney Disease with Albuminuria/Proteinuria:

• Include RAS blocker; target systolic BP 120-129 mmHg for eGFR >30 mL/min/1.73m² 2, 3

Heart Failure with Reduced Ejection Fraction:

• Use ACE inhibitor/ARB, beta-blocker, diuretic, and mineralocorticoid receptor antagonist 3

Previous Stroke/TIA:

• Target systolic BP 120-130 mmHg using RAS blockers, calcium channel blockers, and diuretics 2, 3

Coronary Artery Disease:

• Target <130/80 mmHg; use RAS blockers and beta-blockers as first-line 2

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB) due to increased adverse effects without additional benefit 1, 3
• Do not delay pharmacological treatment in confirmed hypertension ≥140/90 mmHg while pursuing lifestyle modifications alone 1, 3
• Avoid monotherapy as initial treatment for most patients with confirmed hypertension, as combination therapy achieves better BP control 1, 2
• Do not overlook the need for lower BP targets (<130/80 mmHg) in high-risk patients with diabetes, CKD, or established CVD 2, 3

Medication Timing and Adherence

• Take medications at the most convenient time of day to establish habitual pattern and improve adherence 1
• Establish routine pattern regarding meals (high-fat meals can decrease absorption of some agents) 6
• Utilize single-pill fixed-dose combinations whenever possible 1, 2, 3

Monitoring and Long-Term Management

• Monitor BP using both office and home readings regularly 3
• Reassess cardiovascular risk annually 2, 3
• Continue BP-lowering treatment lifelong if well tolerated, even beyond age 85 years 1, 3