What is the treatment for a patient with stage 2 hypertension (blood pressure of 190/80 mmHg)?

Treatment of Blood Pressure 190/80 mmHg

For a patient with stage 2 hypertension (BP 190/80 mmHg), immediate initiation of combination pharmacological therapy with two antihypertensive agents plus lifestyle modifications is recommended, targeting a blood pressure goal of <130/80 mmHg. 1

Classification and Immediate Action

• A BP of 190/80 mmHg is classified as stage 2 hypertension (≥160/100 mmHg by systolic criteria), which mandates immediate drug treatment without delay. 1
• This level of blood pressure significantly increases cardiovascular risk and requires prompt intervention to reduce morbidity and mortality. 2

Pharmacological Treatment Strategy

Initial Combination Therapy

Start with two-drug combination therapy immediately rather than monotherapy, as most patients with stage 2 hypertension require multiple agents to achieve BP control. 1, 2

For non-Black patients, the preferred initial combination is:

• ACE inhibitor or ARB (low dose initially) PLUS
• Dihydropyridine calcium channel blocker (e.g., amlodipine) OR thiazide/thiazide-like diuretic (e.g., chlorthalidone, hydrochlorothiazide) 1, 3

For Black patients, the preferred initial combination is:

• ARB (low dose) PLUS dihydropyridine calcium channel blocker OR thiazide/thiazide-like diuretic 1

• Single-pill combination formulations are strongly preferred to improve adherence and simplify the regimen. 1

Dose Titration and Escalation

• Increase to full doses of the initial two-drug combination if BP target is not achieved within 1 month. 1, 2
• If BP remains uncontrolled with two drugs at full doses, escalate to three-drug combination: RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1
• If still uncontrolled, add spironolactone as the fourth agent (or alternatives: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker if spironolactone is contraindicated or not tolerated). 1

Blood Pressure Goals

Target BP is <130/80 mmHg for most adults, with treatment aimed at achieving this within 3 months. 1, 2

• For adults <65 years: systolic BP 120-129 mmHg is optimal if well tolerated. 1
• For adults ≥65 years: systolic BP <130 mmHg. 3
• Aim to reduce BP by at least 20/10 mmHg from baseline. 1, 2
• Individualize targets for patients ≥85 years, those with frailty, or symptomatic orthostatic hypotension, using the "as low as reasonably achievable" (ALARA) principle if standard targets are not tolerated. 1

Lifestyle Modifications (Concurrent with Medications)

Implement the following evidence-based lifestyle interventions immediately alongside pharmacotherapy:

• Weight reduction: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women). 1
• Dietary modifications: Adopt DASH or Mediterranean diet patterns with sodium restriction to <2,300 mg/day (ideally <1,500 mg/day) and increased potassium intake. 1, 3
• Physical activity: 150 minutes/week of moderate-intensity aerobic exercise plus resistance training 2-3 times/week. 1
• Alcohol limitation: Reduce to <100 g/week of pure alcohol (approximately 7 standard drinks/week), or preferably avoid completely. 1
• Tobacco cessation: Complete smoking cessation with referral to cessation programs. 1

Monitoring and Follow-Up

• Reassess BP within 1 month after initiating therapy to evaluate response and adjust medications. 2
• Achieve target BP within 3 months of treatment initiation. 1
• Consider home BP monitoring (target <135/85 mmHg) or 24-hour ambulatory BP monitoring (target <130/80 mmHg) to confirm office readings and detect white-coat or masked hypertension. 1
• Monitor for medication adherence, as non-adherence is a leading cause of treatment failure. 2, 4
• Check renal function and serum potassium when using ACE inhibitors, ARBs, or aldosterone antagonists. 1

Special Considerations and Risk Assessment

• Assess for secondary hypertension if BP is difficult to control or patient is young (<40 years), particularly looking for renal artery stenosis, primary aldosteronism, pheochromocytoma, or obstructive sleep apnea. 2, 4
• Evaluate for target organ damage: Consider echocardiography to assess for left ventricular hypertrophy, check urinalysis for proteinuria/albuminuria, and assess renal function. 1, 2
• Calculate cardiovascular risk: For patients with diabetes, chronic kidney disease, or established cardiovascular disease, treatment is particularly urgent as these represent high-risk conditions. 1

Common Pitfalls to Avoid

• Therapeutic inertia: Do not delay escalation of therapy if BP remains uncontrolled; failure to intensify treatment is a major cause of poor BP control. 2
• Inadequate dosing: Ensure medications are prescribed at optimal doses before adding additional agents. 4
• Combining two RAS blockers: Never combine an ACE inhibitor with an ARB, as this increases adverse events without additional benefit. 1
• Excessive rapid BP reduction: In chronic hypertension, avoid reducing BP to normal values too rapidly (except in aortic dissection or pulmonary edema), as this can cause hypoperfusion due to altered autoregulation. 5
• Ignoring medication adherence: Address barriers to adherence including cost, side effects, and complexity of regimen; single-pill combinations significantly improve adherence. 2

Medication Timing

• Medications should be taken at the most convenient time for the patient to establish a consistent routine and improve adherence; there is no evidence that nighttime dosing is superior to morning dosing for cardiovascular outcomes. 1