What are the treatment options for hypertension?

Treatment Options for Hypertension

First-Line Pharmacological Treatment

For adults with confirmed hypertension requiring pharmacological treatment, initiate therapy with any of four first-line drug classes: thiazide or thiazide-like diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs), or long-acting dihydropyridine calcium channel blockers. 1

Preferred Initial Approach: Combination Therapy

• Start most patients on combination therapy with two first-line agents, preferably as a single-pill combination to improve adherence. 1, 2
• Preferred combinations include a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic. 2
• Single-pill combinations enhance medication adherence and persistence compared to multiple separate pills. 1, 2

Monotherapy Considerations

• Monotherapy may be appropriate for select patients with lower baseline blood pressure or specific clinical circumstances. 3
• When using monotherapy, any of the four first-line drug classes is acceptable based on patient-specific factors. 1

Blood Pressure Thresholds for Initiating Treatment

Standard Hypertension (≥140/90 mmHg)

• Initiate pharmacological treatment for all individuals with confirmed hypertension and systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg. 1
• This is a strong recommendation based on moderate-to-high quality evidence. 1

Lower Threshold (130-139 mmHg systolic)

• For patients with existing cardiovascular disease and systolic BP 130-139 mmHg, initiate pharmacological treatment. 1
• Consider pharmacological treatment for patients without CVD but with high cardiovascular risk, diabetes mellitus, or chronic kidney disease when systolic BP is 130-139 mmHg. 1
• CVD risk assessment should not delay treatment initiation; it can be performed after starting therapy. 1

Target Blood Pressure Goals

General Population

• Target BP <140/90 mmHg for all patients with hypertension without comorbidities. 1

High-Risk Patients

• Target systolic BP <130 mmHg for patients with known cardiovascular disease. 1
• Target systolic BP <130 mmHg for high-risk patients (those with high CVD risk, diabetes mellitus, or chronic kidney disease). 1
• For adults <65 years, aim for BP <130/80 mmHg. 2
• For adults ≥65 years, target systolic BP 120-130 mmHg if tolerated. 2

Treatment Intensification Algorithm

Step 1: Initial Dual Therapy

• Begin with two-drug combination at low doses (RAS blocker + calcium channel blocker OR RAS blocker + thiazide/thiazide-like diuretic). 2

Step 2: Triple Therapy

• If BP remains uncontrolled, advance to triple therapy with RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1, 2
• This combination addresses multiple pathophysiological mechanisms of hypertension. 2

Step 3: Resistant Hypertension Management

• Resistant hypertension is defined as uncontrolled BP despite three or more drugs including a diuretic. 1, 2
• Add low-dose spironolactone (aldosterone antagonist) as the fourth agent. 2
• Reinforce lifestyle modifications and assess medication adherence before adding additional agents. 2
• Consider referral to hypertension specialist for further evaluation of secondary causes. 2

Special Population Considerations

Black Patients

• Initial treatment should include a diuretic or calcium channel blocker, either alone or in combination with a RAS blocker. 2

Patients with Diabetes or CKD with Proteinuria

• A RAS blocker (ACE inhibitor or ARB) should be included in the treatment regimen. 2
• For CKD patients with eGFR >30 mL/min/1.73m², target systolic BP 120-129 mmHg. 2

Elderly Patients

• Treatment may need more gradual initiation with consideration of frailty and comorbidities. 2
• Target systolic BP 120-130 mmHg if tolerated in those ≥65 years. 2

Metabolic Syndrome

• Prefer ACE inhibitors or ARBs as they are associated with lower incidence of new-onset diabetes. 1
• Add dihydropyridine calcium channel blocker if needed, as these are metabolically neutral. 1
• Avoid or use beta-blockers cautiously due to adverse metabolic effects (weight gain, insulin resistance, dyslipidemia), though newer vasodilating beta-blockers like carvedilol and nebivolol have fewer metabolic effects. 1
• Low-dose thiazide diuretics may be considered as second or third-line agents. 1

Essential Lifestyle Modifications

All patients with hypertension should receive recommendations for lifestyle modifications, which enhance the efficacy of pharmacological therapy. 2, 3

• Weight loss for overweight/obese patients 2, 3
• DASH dietary pattern (high in fruits, vegetables, whole grains, low-fat dairy) 2, 3
• Sodium restriction to <2.3 g/day (ideally <1.5 g/day) 2, 3
• Increased potassium intake through diet 2, 3
• Regular physical activity (at least 150 minutes/week of moderate-intensity aerobic exercise) 2, 3
• Moderation or elimination of alcohol consumption 2, 3
• Smoking cessation 2

The BP-lowering effects of individual lifestyle components are partially additive. 3

Follow-Up Schedule

• Monthly follow-up after initiation or change in antihypertensive medications until target BP is achieved. 1
• Follow-up every 3-5 months for patients with controlled BP. 1
• Implement home blood pressure monitoring to provide feedback and improve adherence. 2

Critical Pitfalls to Avoid

Drug Combination Errors

• Never combine two RAS blockers (ACE inhibitor + ARB) due to increased adverse effects without additional cardiovascular benefit. 2

Treatment Inertia

• Avoid delayed intensification of therapy when BP remains uncontrolled. 2
• Assess medication adherence thoroughly before adding new medications or increasing doses. 2

Inappropriate Agents for Hypertensive Emergencies

• Do not use immediate-release nifedipine, hydralazine, or nitroglycerin as first-line therapy for hypertensive emergencies. 4, 5
• Use sodium nitroprusside with extreme caution due to significant toxicity; it should generally be avoided. 4, 5

Excessive BP Lowering

• Rapid and uncontrolled BP lowering in hypertensive emergencies can lead to complications. 1
• In acute intracerebral hemorrhage, avoid excessive acute drops in systolic BP (>70 mmHg) as this may cause acute renal injury and neurological deterioration. 1

Hypertensive Emergencies vs. Urgencies

Hypertensive Emergency (Acute End-Organ Damage Present)

• Defined as severe BP elevation (typically >180/120 mmHg) with acute target organ damage (cardiac, renal, neurologic, retinal). 1, 4
• Requires immediate BP reduction with short-acting, titratable intravenous antihypertensive agents in an intensive care unit setting. 1, 4
• Preferred IV agents include labetalol, esmolol, fenoldopam, nicardipine, and clevidipine. 4, 5
• Establish affected target organ(s) and determine if specific interventions beyond BP lowering are needed. 1

Hypertensive Urgency (No Acute End-Organ Damage)

• Severe hypertension without clinical evidence of acute organ damage. 1
• Treat with oral antihypertensive medications; hospital admission usually not required. 1
• Use standard oral agents according to the treatment algorithm; more urgent outpatient follow-up is needed. 1

Medication Adherence Strategies

• Prescribe single-pill combinations whenever possible. 2
• Use once-daily dosing regimens. 2
• Implement home BP monitoring for patient feedback. 2
• Consider multidisciplinary approaches involving pharmacists and nurses with proper training, prescribing authority, and physician oversight. 1, 2

Laboratory Testing

• Obtain tests to screen for comorbidities when starting pharmacologic therapy, but only when testing does not delay or impede treatment initiation. 1
• Testing should not be mandatory before starting treatment in most cases. 1

Clinical Impact of Treatment

A systolic BP reduction of 10 mmHg decreases the risk of cardiovascular events by approximately 20-30%. 3 This substantial benefit underscores the importance of achieving target BP goals through appropriate pharmacological and lifestyle interventions.