What are the diagnostic and treatment options for hypertension?

Diagnosis and Treatment of Hypertension

Diagnosis

Hypertension is diagnosed when office blood pressure is ≥130/85 mmHg on repeated measurements, confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg). 1

Blood Pressure Measurement

• Use validated automated upper arm cuff devices with appropriate cuff size 1
• At first visit, measure BP in both arms simultaneously; use the arm with higher readings for subsequent measurements 1
• Diagnosis requires average of 2-3 readings on at least 2 separate occasions 1
• Confirm elevated office readings with home or ambulatory BP monitoring to exclude white coat hypertension 1

Initial Evaluation

Physical Examination - Look for:

• Pulse rate, rhythm, and character; jugular venous pressure 1
• Apex beat displacement, extra heart sounds, basal crackles, peripheral edema 1
• Carotid, abdominal, and femoral bruits; radio-femoral delay (coarctation) 1
• Enlarged kidneys, neck circumference >40 cm (sleep apnea), enlarged thyroid 1
• Increased BMI/waist circumference (>94 cm men, >80 cm women), Cushingoid features 1

Essential Laboratory Tests:

• Serum sodium, potassium, creatinine with eGFR calculation 1
• Fasting glucose and lipid profile 1
• Urinalysis (dipstick for proteinuria) 1
• 12-lead ECG (detect atrial fibrillation, left ventricular hypertrophy, ischemia) 1

Additional Testing When Indicated:

• Echocardiography for LVH or systolic/diastolic dysfunction 1
• Urinary albumin-to-creatinine ratio 1
• Serum uric acid 1
• For suspected secondary hypertension: aldosterone-renin ratio, plasma metanephrines, late-night salivary cortisol 1
• Renal artery imaging (ultrasound, CT/MR angiography) only when clinically indicated 1

Cardiovascular Risk Assessment

• Assess 10-year CVD risk using validated calculators 1
• Consider age >65 years, male sex, diabetes, elevated LDL-cholesterol, family history of CVD, smoking, target organ damage 1

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Treatment

For confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications and pharmacological treatment promptly to reduce cardiovascular risk. 1

Blood Pressure Targets

Target systolic BP of 120-129 mmHg in most adults, provided treatment is well tolerated. 1

• For adults <65 years: <130/80 mmHg 1
• For adults ≥65 years: systolic <130 mmHg 1
• For patients aged ≥85 years or with moderate-to-severe frailty: individualize based on tolerability, but maintain treatment lifelong if well tolerated 1
• If target 120-129 mmHg not achievable, use "as low as reasonably achievable" (ALARA) principle 1

Lifestyle Modifications (All Patients)

Lifestyle changes are recommended for all patients with elevated BP and can reduce BP by 5-10/2-6 mmHg. 1, 2

• Weight loss: Aim for BMI 20-25 kg/m² and waist circumference <94 cm (men), <80 cm (women); 10 kg weight loss reduces BP by ~6/4.6 mmHg 1
• Dietary pattern: Adopt Mediterranean or DASH diet (emphasizes fruits, vegetables, low-fat dairy, reduced saturated fat and cholesterol) 1, 2, 3
• Sodium restriction: Limit to <2.3 g/day (ideally <1.5 g/day); reduces BP by 5-10/2-6 mmHg 1, 3
• Potassium supplementation: Increase dietary potassium intake 1, 3
• Physical activity: 150 minutes/week moderate-intensity aerobic exercise, complemented with resistance training 2-3 times/week 1, 2, 3
• Alcohol limitation: <100 g/week pure alcohol (~7-14 drinks/week depending on portion size); preferably avoid completely 1
• Sugar restriction: Limit free sugar to <10% of energy intake; avoid sugar-sweetened beverages 1
• Tobacco cessation: Mandatory; refer to cessation programs 1

Pharmacological Treatment

Combination BP-lowering treatment with a RAS blocker (ACE inhibitor or ARB) plus a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic is recommended as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1

First-Line Drug Classes

• ACE inhibitors (e.g., lisinopril, enalapril) 1, 4, 5, 2
• ARBs (e.g., losartan, candesartan) 1, 4, 2
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2
• Thiazide/thiazide-like diuretics (chlorthalidone, indapamide preferred over hydrochlorothiazide) 1, 2

Treatment Algorithm

Step 1 (Initial Therapy):

• Non-Black patients: RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB OR RAS blocker + thiazide/thiazide-like diuretic 1
• Black patients: ARB + dihydropyridine CCB OR dihydropyridine CCB + thiazide/thiazide-like diuretic 1
• Exception - Consider monotherapy for: Low-risk grade 1 hypertension, patients aged >80 years, frail patients, elevated BP (120-139/70-89 mmHg) with low CVD risk 1

Step 2:

• Increase to full doses of two-drug combination 1
• Use fixed-dose single-pill combinations to improve adherence 1

Step 3:

• Add third drug: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic, preferably as single-pill combination 1

Step 4 (Resistant Hypertension):

• Add spironolactone (mineralocorticoid receptor antagonist) as fourth-line agent 1, 6
• If spironolactone not tolerated or contraindicated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Special Considerations

Beta-blockers:

• Not first-line for uncomplicated hypertension 1
• Combine with other classes when compelling indications exist: angina, post-MI, heart failure with reduced ejection fraction, heart rate control 1
• Avoid in metabolic syndrome due to adverse effects on glucose metabolism and weight 1

Dual RAS blockade:

• Combining ACE inhibitor + ARB is NOT recommended 1

Medication timing:

• Take at most convenient time to establish habitual pattern and improve adherence 1
• Once-daily dosing preferred 1

Specific Clinical Scenarios

Elevated BP (120-139/70-89 mmHg) with High CVD Risk:

• Initiate lifestyle modifications immediately 1
• After 3 months of lifestyle intervention, start pharmacological treatment if BP remains ≥130/80 mmHg 1

Diabetes:

• Target BP <130/80 mmHg (<140/80 in elderly) 1
• Prefer RAS inhibitor + CCB and/or thiazide-like diuretic 1
• Add statin for LDL-C >70 mg/dL (with target organ damage) or >100 mg/dL (uncomplicated) 1

Coronary Artery Disease:

• Target BP <130/80 mmHg (<140/80 in elderly) 1
• First-line: RAS blockers, beta-blockers ± CCBs 1
• LDL-C target <55 mg/dL (1.4 mmol/L) 1
• Antiplatelet therapy with aspirin 1

Heart Failure:

• Target BP <130/80 mmHg but >120/70 mmHg 1
• HFrEF: RAS blockers, beta-blockers, mineralocorticoid receptor antagonists; consider ARNI (sacubitril-valsartan) 1
• CCBs only if poor BP control 1

Chronic Kidney Disease:

• RAS inhibitors preferred 1
• Use loop diuretics instead of thiazides when eGFR significantly reduced 1

Previous Stroke:

• Target BP <130/80 mmHg (<140/80 in elderly) 1
• First-line: RAS blockers, CCBs, diuretics 1
• Antiplatelet therapy for ischemic stroke only 1

Resistant Hypertension Management

Resistant hypertension is defined as BP ≥130/80 mmHg despite adherence to 3 or more antihypertensive agents from different classes at optimal doses (including a diuretic), or requiring 4 or more medications. 1, 6

Before diagnosing true resistant hypertension:

• Confirm with home or ambulatory BP monitoring (exclude white coat effect) 1
• Assess medication adherence objectively (pharmacy records, pill counting, electronic monitoring) 1
• Identify interfering substances: NSAIDs, stimulants, oral contraceptives, excessive alcohol 1
• Screen for secondary causes: primary aldosteronism, renal artery stenosis, pheochromocytoma, obstructive sleep apnea 1, 6

Treatment approach:

• Maximize diuretic therapy: use chlorthalidone or indapamide instead of hydrochlorothiazide 1
• Add spironolactone 25-50 mg daily (most effective fourth-line agent) 1, 6
• Intensify lifestyle modifications, especially weight loss and sodium restriction 1
• Simplify regimen with single-pill combinations and once-daily dosing 1
• Consider multidisciplinary team approach (pharmacists, nurse case managers, nutritionists) 1
• Refer to hypertension specialist if BP remains uncontrolled 1

Monitoring and Follow-Up

• Achieve target BP within 3 months of treatment initiation 1
• Monitor BP control with office measurements and home BP monitoring 1
• Maintain BP-lowering treatment lifelong, even beyond age 85 if well tolerated 1
• Assess adherence at each visit using objective methods when possible 1
• Monitor for adverse effects and adjust therapy accordingly 1

Common Pitfalls to Avoid

• Inaccurate BP measurement: Always use validated devices with proper technique and cuff size 1
• Inadequate diuretic therapy: Thiazide-like diuretics (chlorthalidone, indapamide) are more effective than hydrochlorothiazide 1
• Monotherapy in most patients: Combination therapy is more effective and recommended as initial treatment 1
• Ignoring pseudoresistance: Rule out white coat hypertension, poor adherence, and interfering substances before diagnosing resistant hypertension 1
• Overlooking secondary causes: Screen when clinically indicated (young age, sudden onset, severe/resistant hypertension) 1, 6
• Excessive BP lowering in elderly: Avoid diastolic BP <65 mmHg in patients >80 years 1