What are the initial management steps for hypertension?

Initial Management of Hypertension

Start all patients with confirmed hypertension (BP ≥140/90 mmHg) on immediate combination drug therapy alongside lifestyle modifications—do not delay pharmacological treatment. 1

Confirming the Diagnosis

Before initiating treatment, confirm hypertension using proper measurement technique:

• Use a validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at the first visit and using the arm with higher readings for subsequent measurements. 1, 2
• Office BP ≥140/90 mmHg defines hypertension, but must be confirmed with either home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg). 1, 2
• Assess for target organ damage (left ventricular hypertrophy, retinopathy, proteinuria), cardiovascular risk factors, diabetes, chronic kidney disease, and screen for secondary causes if clinically indicated (young age, severe/resistant hypertension, hypokalemia). 1, 2

Lifestyle Modifications (Start Immediately for All Patients)

Implement all of the following evidence-based lifestyle changes, which provide additive BP-lowering effects: 3

• Dietary pattern: Follow DASH or Mediterranean diet—rich in fruits, vegetables, low-fat dairy products, fiber, and minerals (calcium, potassium, magnesium) with reduced sodium intake. 1
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly plus resistance training 2-3 times per week. 1
• Weight management: Target BMI 20-25 kg/m² and healthy waist circumference. 1
• Alcohol: Limit to less than 100g/week of pure alcohol, or preferably complete avoidance. 1
• Smoking: Complete cessation with appropriate supportive care. 1

These lifestyle modifications reduce BP by approximately 5-10 mmHg systolic when combined and enhance the efficacy of pharmacological therapy. 3

Initial Pharmacological Therapy

For Non-Black Patients

Start with two-drug combination therapy as a single-pill combination—this is superior to sequential monotherapy titration. 1, 2

The preferred initial regimen is: ACE inhibitor (or ARB) + dihydropyridine calcium channel blocker 1, 2

• Alternative: ACE inhibitor (or ARB) + thiazide/thiazide-like diuretic 4, 1
• Example dosing: Lisinopril 10 mg + amlodipine 5 mg once daily 5

For Black Patients

The preferred initial approach is: ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide/thiazide-like diuretic 4, 2

• Black patients respond better to calcium channel blockers and diuretics than to RAS blockers as monotherapy 4

Exceptions to Combination Therapy

Consider monotherapy only for: 1

• Low-risk grade 1 hypertension (BP 140-159/90-99 mmHg with low cardiovascular risk)
• Patients >80 years old
• Frail patients

Start with 5 mg lisinopril or equivalent in these populations. 5

Blood Pressure Targets

Target BP <130/80 mmHg for most adults under 65 years. 1

For adults 65-85 years: Target systolic BP 120-129 mmHg if well tolerated. 1

For adults >85 years: Individualize based on frailty, with systolic BP 130-139 mmHg if well tolerated. 1

For patients with diabetes, CKD, or established CVD: Target <130/80 mmHg. 2

The evidence is clear that lowering systolic BP by 10 mmHg reduces cardiovascular events by 20-30%. 3

Escalation Algorithm

If BP remains uncontrolled after 2-4 weeks on dual therapy: 1, 2

Step 1: Increase to three-drug combination: RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic 4, 1

Step 2: If still uncontrolled (resistant hypertension), add spironolactone 25 mg once daily 4, 1

Step 3: If spironolactone not tolerated or ineffective, consider eplerenone, amiloride, higher-dose thiazide, or loop diuretic 4

Step 4: Add bisoprolol or doxazosin as fifth-line agents 4

Monitoring and Follow-Up

Schedule follow-up within 2-4 weeks initially to assess response and tolerability. 2

Achieve target BP within 3 months of initiating treatment. 1, 2

Check serum creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 1, 2

Use home BP monitoring to guide medication adjustments and improve long-term control. 1

Critical Pitfalls to Avoid

Never combine two RAS blockers (ACE inhibitor + ARB)—this is potentially harmful and increases risk of hyperkalemia, hypotension, and acute kidney injury without additional benefit. 1, 2

Avoid clinical inertia—immediate combination therapy is more effective than sequential monotherapy titration and achieves target BP faster. 2

Do not discontinue lifestyle modifications once drug therapy starts—they are complementary and may reduce medication requirements. 2

Do not use inadequate diuretic dosing—chlorthalidone 12.5-25 mg is preferred over hydrochlorothiazide due to superior 24-hour BP control and cardiovascular outcomes. 6, 3