What are the guidelines for initiating and managing blood pressure medication for hypertension?

Blood Pressure Medication Guidelines

When to Initiate Drug Therapy

Initiate antihypertensive medication immediately for all adults with sustained blood pressure ≥140/90 mmHg, regardless of cardiovascular risk level. 1, 2

For patients with blood pressure 130-139/80-89 mmHg:

• Start drug therapy immediately if high or very high cardiovascular risk (10-year CVD risk ≥20%, diabetes, chronic kidney disease, or established cardiovascular disease) 1, 2
• If moderate cardiovascular risk, attempt lifestyle modifications for up to 3 months; if blood pressure remains uncontrolled, initiate drug therapy 2

For patients with blood pressure ≥160/100 mmHg, drug treatment should be started despite non-pharmacological measures 3

Initial Pharmacological Approach

Start with two-drug combination therapy as a single-pill combination for most patients requiring medication. 1, 2 This approach is more effective than sequential monotherapy titration and avoids clinical inertia. 1

For Non-Black Patients:

• Low-dose ACE inhibitor or ARB + dihydropyridine calcium channel blocker 1, 2

For Black Patients:

• Low-dose ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic 1, 2

Critical Contraindication:

Never combine two RAS blockers (ACE inhibitor + ARB) as this is potentially harmful. 1

Blood Pressure Targets

Target blood pressure is <130/80 mmHg for most adults, including those with diabetes, chronic kidney disease, or established cardiovascular disease. 1, 2, 4

• Initial goal: reduce blood pressure by at least 20/10 mmHg 1, 2
• Achieve target within 3 months of initiating treatment 1, 2
• For adults ≥65 years: SBP <130 mmHg 4

The British Hypertension Society guidelines recommend ≤140/85 mmHg for most patients, with lower targets of ≤130/80 mmHg for patients with diabetes, renal impairment, or established cardiovascular disease 3, though these are older recommendations and the more recent American guidelines favor the lower <130/80 mmHg target universally. 1, 2

Lifestyle Modifications

Implement lifestyle interventions for all patients with elevated blood pressure, even when starting drug therapy. 1, 2 These modifications complement blood pressure lowering effects of drugs and may reduce the dose or number of drugs required. 3, 1

Dietary Changes:

• DASH or Mediterranean diet rich in fruits, vegetables, low-fat dairy products, and low in saturated fat 1, 2, 4, 5
• Reduce sodium intake to <5 g salt (2,000 mg sodium) per day 2, 4, 5
• Increase potassium intake through dietary sources 1, 4, 5

Physical Activity:

• At least 150 minutes of moderate-intensity aerobic exercise weekly plus resistance training 2-3 times per week 1
• Regular physical activity designed to improve fitness, predominantly dynamic (brisk walking) rather than isometric (weight training) 3, 4

Weight Management:

• Achieve and maintain healthy body mass index through reduced fat and total calorie intake 3, 4, 6

Alcohol and Smoking:

• Limit alcohol to <21 units/week for men and <14 units/week for women 3
• Smoking cessation 1, 4

Monitoring and Follow-Up

Schedule follow-up within 2-4 weeks after initiating or adjusting therapy to assess response and tolerability. 1, 2

• Implement home blood pressure monitoring to track progress and improve medication adherence 2
• Check serum creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Confirm hypertension diagnosis using validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms and using the higher reading 1
• Office BP ≥140/90 mmHg must be confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 1

Dose Titration

Allow at least four weeks to observe the full response to medication adjustments, unless more urgent blood pressure lowering is necessary. 3 The drug dose should be titrated up according to manufacturers' instructions, except for thiazides or thiazide-like diuretics where the ideal dose is uncertain. 3

Special Situations Requiring Urgent Treatment

Immediate treatment is needed for: 3

• Accelerated hypertension (severe hypertension with grade III-IV retinopathy)
• Particularly severe hypertension (>220/120 mmHg)
• Impending complications (transient ischemic attack, left ventricular failure)

Adjunctive Therapies

Aspirin:

• Use 75 mg daily if patient is aged ≥50 years with blood pressure controlled to <150/90 mmHg AND has target organ damage, diabetes, or 10-year CVD risk ≥20% 3
• Use for all patients with established cardiovascular disease unless contraindicated 3

Statins:

• Use for all patients with hypertension complicated by cardiovascular disease, irrespective of baseline cholesterol 3
• For primary prevention: use if 10-year CVD risk ≥20% and total cholesterol ≥3.5 mmol/L 3
• Target: lower total cholesterol by 25% or LDL by 30%, or reach <4.0 mmol/L or <2.0 mmol/L respectively, whichever is greater 3

Common Pitfalls to Avoid

• Do not delay treatment in high-risk patients as delays are associated with worse cardiovascular outcomes 2
• Do not discontinue lifestyle modifications once drug therapy starts—they are complementary and may reduce medication requirements 1
• Avoid monotherapy titration when combination therapy is indicated—immediate combination therapy is more effective 1
• Most patients will require at least two blood pressure lowering drugs to achieve recommended goals 3, 7