How to manage a patient with stage 2 hypertension?

Management of Stage 2 Hypertension (BP 170/80 mmHg)

Initiate immediate dual-agent antihypertensive therapy with two medications from different classes, targeting a blood pressure goal of <130/80 mmHg. 1

Immediate Treatment Approach

Pharmacological Therapy - Start Now

Begin combination therapy immediately with two first-line agents from different classes: 1

• Preferred initial combinations:

  • Thiazide/thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) + ACE inhibitor (e.g., lisinopril) 1
  • Thiazide/thiazide-like diuretic + calcium channel blocker (dihydropyridine such as amlodipine) 1
  • ACE inhibitor or ARB + calcium channel blocker 1

• Use single-pill combination therapy when possible to improve adherence 1

Why Two Drugs Immediately?

The 2017 ACC/AHA guidelines specifically recommend initiating two antihypertensive agents when SBP and DBP are more than 20 and 10 mmHg above target, respectively. 1 With a BP of 170/80 mmHg, this patient's systolic pressure is 40 mmHg above the <130 mmHg target, clearly meeting criteria for dual therapy. 1

Blood Pressure Target

Target BP: <130/80 mmHg for most adults, with the 2024 ESC guidelines recommending an even more aggressive target of 120-129 mmHg systolic if well tolerated. 1

The evidence supporting this lower target is strong, with systematic reviews showing continuing reduction in cardiovascular events (stroke, coronary heart disease, all-cause mortality) at progressively lower achieved systolic BP levels. 1

Concurrent Lifestyle Modifications

Implement these evidence-based interventions simultaneously with medications: 1, 2

• Weight reduction: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• DASH or Mediterranean diet with sodium restriction 1, 2
• Limit alcohol: <100 g/week of pure alcohol (preferably avoid completely) 1
• Physical activity: Regular aerobic exercise plus resistance training 2-3 times weekly 1
• Smoking cessation if applicable 1

Follow-Up Schedule

Reassess in 1 month with monthly evaluations until BP control is achieved. 1

At each visit: 1

• Measure BP using standardized technique
• Assess medication adherence
• Monitor for adverse effects
• Check electrolytes and renal function 2-4 weeks after initiating ACE inhibitor or diuretic therapy 1
• Adjust medications promptly if target not achieved

Escalation Strategy

If BP remains uncontrolled on two agents, escalate to three-drug combination (RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic), preferably as a single-pill combination. 1

Special Considerations

Assess for Secondary Causes if:

• Age <30 years with severe hypertension 3
• Sudden onset or worsening despite treatment 3
• Resistant hypertension (uncontrolled on ≥3 drugs including a diuretic) 1, 3

Cardiovascular Risk Assessment

Calculate 10-year ASCVD risk to guide intensity of overall cardiovascular risk reduction strategies. 1 Consider adding statin therapy if indicated by risk assessment. 4

Race-Specific Considerations

In Black patients, thiazide diuretics and calcium channel blockers are preferred first-line agents, as β-blockers and renin-angiotensin system inhibitors are less effective at lowering BP in this population. 1

Critical Pitfalls to Avoid

• Do not delay treatment - Stage 2 hypertension requires prompt initiation of therapy 1
• Do not start with monotherapy when BP is >20/10 mmHg above target 1
• Do not combine two RAS blockers (ACE inhibitor + ARB) - this is not recommended 1
• Do not assume "white coat effect" without confirmation via home BP monitoring or ambulatory BP monitoring 1
• Do not discontinue therapy even if BP normalizes - lifelong treatment is recommended 1