What is the management plan for a patient with hypertension (high blood pressure)?

Management of Blood Pressure 170/82 mmHg

This patient requires confirmation of hypertension through out-of-office blood pressure monitoring, comprehensive cardiovascular risk assessment, and likely initiation of combination antihypertensive therapy targeting systolic BP 120-129 mmHg. 1

Immediate Diagnostic Confirmation

Confirm the diagnosis with out-of-office measurements before initiating treatment, as office readings can overestimate true BP. 2

• Obtain home blood pressure monitoring (HBPM) or 24-hour ambulatory blood pressure monitoring (ABPM) to confirm sustained hypertension 1
• Office BP of 170/82 mmHg represents Grade 2 hypertension (systolic ≥160 mmHg), but confirmation prevents overtreatment of white-coat hypertension 1

Essential Initial Workup

Perform these specific tests to assess cardiovascular risk and detect target organ damage:

• Serum creatinine and estimated glomerular filtration rate (eGFR) to evaluate kidney function 2
• Urine albumin-to-creatinine ratio (ACR) to detect early kidney damage 2
• 12-lead electrocardiogram to identify left ventricular hypertrophy or prior myocardial infarction 2
• Fasting lipid panel and glucose to calculate 10-year cardiovascular disease risk 1, 3
• Serum potassium to screen for secondary causes like primary aldosteronism 1

Screen for Secondary Hypertension If:

• Patient age <40 years (unless obese, then screen for sleep apnea first) 1
• Sudden onset or worsening of hypertension 1
• Resistant to 3-drug regimen 1
• Hypokalemia with normal/high sodium 1
• Elevated serum creatinine or proteinuria 1

Immediate Lifestyle Interventions

Initiate these evidence-based modifications immediately, regardless of medication decisions:

• Sodium restriction to approximately 2 g/day (most effective dietary intervention) 2
• Mediterranean or DASH dietary pattern with increased fruits/vegetables, reduced saturated fat 2
• Weight reduction if BMI >25 kg/m², targeting BMI 20-25 kg/m² and waist <94 cm (men) or <80 cm (women) 2
• Moderate-intensity aerobic exercise ≥150 minutes/week plus resistance training 2-3 times weekly 2
• Alcohol limitation to <100 g/week or complete cessation 2
• Smoking cessation if applicable, as tobacco independently increases cardiovascular mortality 1

Pharmacological Treatment Decision

With confirmed systolic BP ≥160 mmHg, initiate combination drug therapy immediately alongside lifestyle measures. 1

First-Line Combination Therapy:

Start with a fixed-dose single-pill combination containing: 1, 2

• RAS blocker (ACE inhibitor OR angiotensin receptor blocker) PLUS
• Dihydropyridine calcium channel blocker (e.g., amlodipine) OR
• Thiazide/thiazide-like diuretic (e.g., chlorthalidone, indapamide, hydrochlorothiazide)

Preferred initial combinations: 1, 4, 5

• Lisinopril + amlodipine 4, 5
• Lisinopril + hydrochlorothiazide 4
• ARB + amlodipine 5

Single-pill combinations improve adherence compared to separate pills and are strongly recommended. 1

Escalation Strategy If BP Not Controlled:

If BP remains ≥140/90 mmHg on dual therapy after 3 months: 2, 3

• Add third agent to create triple therapy: RAS blocker + CCB + thiazide diuretic (preferably as single-pill combination) 1, 2

If BP still uncontrolled on triple therapy (resistant hypertension): 1

• Add low-dose spironolactone (25-50 mg daily) as fourth-line agent 1
• If spironolactone not tolerated: consider eplerenone, amiloride, doxazosin, or beta-blocker 1, 2

Never combine ACE inhibitor with ARB - this increases adverse events without additional benefit. 1

Blood Pressure Targets

Target systolic BP 120-129 mmHg if well tolerated in most patients. 1, 2

• Diastolic BP target <80 mmHg but not <70 mmHg to avoid organ hypoperfusion 2
• Achieve target within 3 months of treatment initiation 2
• If patient cannot tolerate 120-129 mmHg target due to symptoms, use "as low as reasonably achievable" (ALARA) principle 1

More lenient targets (systolic <140 mmHg) acceptable for: 2

• Age ≥85 years
• Moderate-to-severe frailty
• Symptomatic orthostatic hypotension
• Limited life expectancy

Critical Pitfalls to Avoid

• Do not use beta-blockers as first-line monotherapy unless specific indication exists (post-MI, angina, heart failure, rate control) 1
• Do not delay treatment - Grade 2 hypertension (≥160/100 mmHg) requires prompt pharmacological intervention 1
• Do not target excessive BP reduction - avoid systolic <120 mmHg or diastolic <70 mmHg 2
• Do not use sublingual nifedipine for urgent BP lowering - unpredictable and potentially dangerous 1

Monitoring and Long-Term Management

• Reassess BP and medication tolerance within 2-4 weeks of initiation 3
• Continue treatment lifelong if tolerated, even beyond age 85 years 1
• Annual cardiovascular risk reassessment including lipid management and diabetes screening 3, 6
• Home BP monitoring for ongoing assessment and improved adherence 1

When to Refer or Admit

This patient does NOT require emergency treatment as BP 170/82 mmHg without acute organ damage is hypertensive urgency, not emergency. 1

Refer for specialist evaluation if: 1

• Suspected secondary hypertension based on screening
• Resistant hypertension (uncontrolled on 3+ drugs)
• Age <30 years requiring treatment 1

Immediate hospitalization required only if: 1, 7

• Systolic BP ≥220 mmHg with acute organ damage (hypertensive emergency) 1
• Acute intracerebral hemorrhage, acute aortic dissection, acute pulmonary edema, or acute coronary syndrome 1