What is the management plan for a patient with stage 2 hypertension (blood pressure 149/98 mmHg)?

Management of Blood Pressure 149/98 mmHg

You should immediately initiate combination antihypertensive drug therapy with two agents from different classes alongside lifestyle modifications, with a target blood pressure of <130/80 mmHg to be achieved within 3 months. 1, 2

Classification and Urgency

• Your blood pressure of 149/98 mmHg meets criteria for Stage 2 hypertension (≥140/90 mmHg), which mandates immediate pharmacological intervention without delay 1, 2
• This level significantly elevates your cardiovascular risk and requires prompt treatment to reduce morbidity and mortality 2, 3, 4
• You should be evaluated within 1 month of diagnosis and have repeat blood pressure assessment at that time 1, 2

Immediate Pharmacological Treatment

Start with two-drug combination therapy immediately rather than monotherapy, as most patients with Stage 2 hypertension require multiple agents to achieve control 1, 3, 4

For Non-Black Patients:

• First-line combination: ACE inhibitor or ARB + either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic 1, 3
• Specific options include: losartan 50 mg daily (can increase to 100 mg) combined with amlodipine or chlorthalidone 5, 4

For Black Patients:

• First-line combination: ARB + dihydropyridine calcium channel blocker OR thiazide/thiazide-like diuretic 1, 3
• ACE inhibitors and ARBs are less effective as monotherapy in Black patients, making the CCB or diuretic component essential 1

Dosing Strategy:

• Single-pill combination formulations are strongly preferred to improve adherence and simplify the regimen 1, 3
• If target BP not achieved within 1 month, increase to full doses of both agents 1, 3
• If still uncontrolled with two drugs at full doses, escalate to three-drug combination (ACE inhibitor/ARB + CCB + thiazide diuretic) 1, 3

Blood Pressure Goals

• Target: <130/80 mmHg for most adults under 65 years 1, 2, 4
• For adults ≥65 years: systolic BP <130 mmHg if well tolerated 3, 4
• Aim to reduce BP by at least 20/10 mmHg from baseline 1, 2, 3
• Achieve target within 3 months of treatment initiation 1, 3

Essential Lifestyle Modifications (Start Immediately)

These interventions are additive to medication effects and should begin concurrently with drug therapy 1, 3, 4:

• Weight reduction: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 3
• Dietary sodium restriction: <2,300 mg/day with increased potassium intake 1, 3, 4
• DASH or Mediterranean diet pattern 1, 3, 4
• Physical activity: 150 minutes/week of moderate-intensity aerobic exercise plus resistance training 2-3 times/week 3
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women 1, 4
• Tobacco cessation if applicable 3

Monitoring Protocol

• Reassess BP within 1 month after initiating therapy to evaluate response and adjust medications 1, 2, 3
• Consider home blood pressure monitoring or 24-hour ambulatory monitoring to confirm office readings and detect white-coat or masked hypertension 1, 3
• Monthly follow-up until BP control achieved 1

Critical Evaluation for Secondary Causes

Screen for secondary hypertension if 3, 6:

• Age <40 years with new-onset hypertension
• BP difficult to control despite appropriate therapy
• Sudden worsening of previously controlled BP

Key conditions to evaluate:

• Primary aldosteronism (most common secondary cause) 6
• Renal artery stenosis 3, 6
• Obstructive sleep apnea 3
• Pheochromocytoma 6
• Chronic kidney disease 1

Assessment for Target Organ Damage

Evaluate for 1, 3:

• Left ventricular hypertrophy (ECG or echocardiogram)
• Proteinuria/albuminuria (urine albumin-to-creatinine ratio)
• Renal function (serum creatinine, eGFR)
• Retinopathy (fundoscopic examination if indicated)

Cardiovascular Risk Stratification

• Calculate 10-year ASCVD risk, particularly if diabetes, chronic kidney disease, or established cardiovascular disease present 1, 3
• Patients with diabetes, CKD, or age 50-80 years are automatically high-risk and require immediate treatment 1

Common Pitfalls to Avoid

• Therapeutic inertia (delaying treatment intensification) is a major cause of poor BP control 2
• Inadequate dosing or inappropriate drug combinations lead to treatment failure 2
• Failing to address medication adherence is a common cause of uncontrolled hypertension 2
• Starting with monotherapy in Stage 2 hypertension delays time to BP control 1, 3
• Not using single-pill combinations when available reduces adherence 1, 3