What are the recommended treatments for managing hypertension?

Hypertension Management

For most adults with confirmed hypertension, immediately initiate combination therapy with two first-line agents—specifically a RAS blocker (ACE inhibitor or ARB) combined with either a calcium channel blocker or thiazide/thiazide-like diuretic—preferably as a single-pill combination to improve adherence and achieve target blood pressure. 1, 2

Diagnosis and Confirmation

• Confirm hypertension using multiple measurements with a validated device, patient seated with arm at heart level, taking at least two readings per visit 1, 2
• Calculate 10-year cardiovascular disease risk to guide treatment intensity, particularly for borderline hypertension (130-139/80-89 mmHg) 1, 2
• Perform routine investigations including urine testing, blood electrolytes, creatinine, glucose, cholesterol, and 12-lead ECG 2
• Consider ambulatory blood pressure monitoring for unusual BP variability, suspected white coat hypertension, or resistant hypertension 2

Lifestyle Modifications (Foundation for All Patients)

Weight and Diet:

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1, 3
• Reduce sodium intake to <2,300 mg/day 3, 4
• Consume 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 3
• Restrict free sugar to maximum 10% of energy intake and eliminate sugar-sweetened beverages 2, 3

Physical Activity:

• Minimum 150 minutes/week of moderate-intensity aerobic activity or 75 minutes/week of vigorous activity 1, 2
• Add resistance training 2-3 times weekly 1, 2

Substance Use:

• Limit alcohol to ≤2 drinks/day for men and ≤1 drink/day for women 3, 4
• Complete tobacco cessation with referral to smoking cessation programs 2, 3

Pharmacological Treatment Algorithm

Step 1: Initial Two-Drug Combination

• Start with RAS blocker (ACE inhibitor like lisinopril 5 or ARB like losartan 6) PLUS either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic 1, 2, 3
• Prescribe as single-pill fixed-dose combination whenever possible to enhance adherence 1, 2
• Lowering blood pressure reduces fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarction 6, 5

Step 2: Escalation to Triple Therapy

• If BP remains uncontrolled after 4 weeks, escalate to three-drug combination: RAS blocker + CCB + thiazide/thiazide-like diuretic 1, 2, 3
• Continue preferring single-pill combinations 1, 2

Step 3: Resistant Hypertension

• Add spironolactone as fourth-line therapy 2

Blood Pressure Targets

Standard Adults (<65 years):

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

Older Adults (≥65 years):

• Target systolic BP 130-139 mmHg 1, 2
• For patients ≥85 years or with symptomatic orthostatic hypotension, consider more lenient targets (<140/90 mmHg) 2

High-Risk Patients:

• Target <130/80 mmHg for patients with diabetes, chronic kidney disease, or established cardiovascular disease 1, 2, 3

Special Population Considerations

Black Patients:

• Initial therapy should include a thiazide-like diuretic plus CCB, or CCB plus ARB 1, 2, 3
• Note: Some antihypertensive drugs have smaller blood pressure effects as monotherapy in Black patients 6, 5, 4

Coronary Artery Disease:

• Target BP <130/80 mmHg and use RAS blockers and beta-blockers as first-line agents 1

Heart Failure:

• For HFrEF: Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists; consider ARNI as alternative to ACE inhibitor/ARB 1, 2
• For HFpEF: Consider SGLT2 inhibitors 2, 3
• Lisinopril is specifically indicated to reduce signs and symptoms of systolic heart failure 5

Previous Stroke/TIA:

• Target systolic BP 120-130 mmHg and use RAS blockers, CCBs, and diuretics as first-line agents 1, 2

Chronic Kidney Disease:

• Include RAS blocker when albuminuria/proteinuria is present 1, 2, 3
• Target systolic BP 120-129 mmHg for eGFR >30 mL/min/1.73m² 1, 2, 3
• RAS blockers provide superior albuminuria reduction 3

Diabetes:

• Initiate treatment at BP ≥140/90 mmHg 1
• Target BP <130/80 mmHg 1, 2, 3
• Losartan is specifically indicated for diabetic nephropathy with elevated serum creatinine and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g) in patients with type 2 diabetes and history of hypertension 6

Left Ventricular Hypertrophy:

• Losartan reduces risk of stroke in hypertensive patients with left ventricular hypertrophy, though this benefit does not apply to Black patients 6

Acute Myocardial Infarction:

• Lisinopril is indicated for reduction of mortality in hemodynamically stable patients within 24 hours of acute MI 5

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB) due to increased adverse effects without additional benefit 1, 2
• Failing to confirm elevated readings with multiple measurements before diagnosis 2
• Not considering white coat hypertension when office readings are elevated 2
• Inadequate dosing or inappropriate combinations of antihypertensive medications 2
• Not addressing lifestyle modifications alongside pharmacological treatment 2
• Overlooking the need for lower BP targets in high-risk patients 2

Monitoring and Follow-Up

• Achieve target BP within 3 months 3
• Regular BP monitoring using both office and home readings 1, 2
• Annual cardiovascular risk reassessment 1, 2
• Monitor renal function and potassium at least annually when using ACE inhibitor, ARB, or diuretic 3
• Continue lifelong BP-lowering treatment if well tolerated, even beyond age 85 1, 2, 3
• Employ multidisciplinary team approaches involving pharmacists to enhance adherence 1