What is the protocol for hypertension management?

Hypertension Management Protocol

Diagnosis and Blood Pressure Measurement

Blood pressure should be measured using a validated device with the patient seated, arm at heart level, taking at least two measurements at each visit to confirm diagnosis before initiating treatment. 1, 2

• Ambulatory blood pressure monitoring (ABPM) is indicated for unusual BP variability, suspected white coat hypertension, or resistant hypertension, with expected values approximately 10/5 mmHg lower than office readings. 1, 2
• Home blood pressure monitoring (HBPM) is the most practical method to document BP for medication titration and is more sensitive than office readings for detecting masked hypertension. 3
• Routine investigations should include urine testing for blood and protein, blood electrolytes and creatinine, blood glucose, serum cholesterol, and 12-lead ECG. 1
• Formal estimation of 10-year cardiovascular disease risk should guide treatment decisions. 1

Treatment Thresholds

Initiate antihypertensive drug therapy if sustained systolic BP ≥160 mmHg or sustained diastolic BP ≥100 mmHg. 3, 1

• For sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg, initiate treatment if any of the following are present: 3, 1

  • Target organ damage
  • Established cardiovascular disease
  • Diabetes mellitus
  • 10-year cardiovascular disease risk ≥20%

• Urgent treatment is needed for accelerated hypertension, severe hypertension (BP ≥180/110 mmHg), or impending complications. 1, 2

Blood Pressure Targets

For most non-diabetic patients, the optimal BP target is <140/85 mmHg (minimum acceptable audit standard <150/90 mmHg). 3, 1

• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, the optimal BP target is <130/80 mmHg (audit standard <140/80 mmHg). 3, 1, 2
• When using ambulatory BP readings, targets should be approximately 10/5 mmHg lower than office BP equivalents. 1

Lifestyle Modifications

All patients with hypertension, borderline, or high-normal blood pressure should receive lifestyle modification recommendations, which can lower systolic BP by approximately 5 mmHg per intervention. 3, 1

Specific Lifestyle Interventions (in order of evidence strength):

• DASH diet: Emphasize fruits, vegetables, whole grains, low-fat dairy products, with reduced saturated and total fat content (SBP reduction ~5 mmHg). 3
• Sodium restriction: Optimal goal <1500 mg/day, but any reduction is beneficial; expect 1-3 mmHg reduction per 1000 mg decrease in sodium intake (linear dose-response). 3
• Weight loss: Achieve ideal body weight; expect approximately 1 mmHg reduction in SBP for every 1 kg weight loss (linear dose-response). 3
• Physical activity: Aerobic exercise (brisk walking) 5-7 times/week for 30-60 minutes/session, aiming for at least 150 minutes/week (SBP reduction ~5 mmHg). 3
• Alcohol moderation: Men ≤2 standard drinks/day; women ≤1 standard drink/day (SBP reduction ~4 mmHg). 3
• Potassium supplementation: Optimal goal 3500-5000 mg/day through dietary sources preferred over pills (SBP reduction ~5 mmHg, nonlinear U-shaped dose-response). 3

Pharmacological Management

Most patients with hypertension will require at least two blood pressure lowering drugs to achieve recommended goals; fixed-dose combinations are preferred when no cost disadvantages exist. 3

First-Line Drug Selection:

• Use fixed-dose combinations as initial therapy, preferably combining a renin-angiotensin system (RAS) blocker with either a dihydropyridine calcium channel blocker or thiazide-like diuretic. 3, 2
• Substitute long-acting chlorthalidone for hydrochlorothiazide (alternatively indapamide) as the preferred thiazide-like diuretic. 3
• Use long-acting amlodipine as first-line calcium channel blocker. 3

Specific Drug Dosing:

• Chlorthalidone: Initiate with 25 mg once daily in the morning with food; if response insufficient, increase to 50 mg daily, then 100 mg daily if needed (dosages above 100 mg daily usually do not increase effectiveness). 4
• Amlodipine: Acts as a peripheral arterial vasodilator with gradual onset of effect; steady-state plasma levels reached after 7-8 days of consecutive daily dosing with terminal elimination half-life of 30-50 hours. 5
• ACE inhibitors (e.g., lisinopril): First-line agents for combination therapy, particularly effective in patients with diabetes, heart failure, or post-myocardial infarction. 6

Medication Titration:

• Allow at least four weeks to observe full response before dose adjustment, unless urgent BP lowering is necessary. 3
• Titrate drug doses according to manufacturers' instructions (except thiazides, where ideal dose is uncertain). 3
• Schedule monthly visits until BP target is achieved. 3

Keys to Effective Blood Pressure Control

The following strategies improve BP control rates: 3

• Agree on BP target with patient
• Replace 30-day with 90-day refills when allowed
• Use telehealth strategies to augment office-based management
• Enhance connectivity between patient, provider, and electronic health record
• Screen for social determinants of health and obstacles to care
• Use multidisciplinary team-based care to enhance lifestyle and medication adherence

Adjunctive Therapy for Cardiovascular Risk Reduction

Aspirin:

• For primary prevention: Use 75 mg daily if patient is ≥50 years with BP controlled to <150/90 mmHg AND has target organ damage, diabetes, or 10-year CVD risk ≥20%. 3
• For secondary prevention: Use for all patients unless contraindicated. 3

Statins:

• For primary prevention: Use sufficient doses to reach targets if patient is up to at least 80 years with 10-year CVD risk ≥20% and total cholesterol ≥3.5 mmol/L. 3
• For secondary prevention (including type 2 diabetes): Use sufficient doses if age up to at least 80 years with total cholesterol ≥3.5 mmol/L. 3
• Target: Lower total cholesterol by 25% or LDL cholesterol by 30%, or reach <4.0 mmol/L or <2.0 mmol/L respectively, whichever is greater. 3

Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis can lead to overdiagnosis and unnecessary treatment. 1
• Not considering white coat hypertension when office readings are elevated; use ABPM or HBPM for confirmation. 1
• Inadequate dosing or inappropriate drug combinations result in poor BP control; most patients need combination therapy. 3, 1
• Not addressing lifestyle modifications alongside pharmacological treatment reduces overall effectiveness. 1
• Overlooking lower BP targets (<130/80 mmHg) in high-risk patients with diabetes, chronic kidney disease, or established CVD increases cardiovascular morbidity. 3, 1, 2
• Not considering secondary causes in resistant hypertension (elevated serum creatinine, proteinuria/hematuria, sudden onset/worsening, young age, electrolyte abnormalities) or when hypertension is resistant to multiple drugs. 1

Monitoring and Follow-up

• Regular BP monitoring using both office and home readings is necessary for optimal management. 1, 2
• Annual reassessment of cardiovascular risk is recommended. 1, 2
• Monitor for adverse effects of medications and adjust therapy as needed. 1
• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence. 2