How do I manage hypertension?

Managing Hypertension

For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate combination pharmacological therapy immediately with a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide diuretic, preferably as a single-pill combination, while simultaneously implementing intensive lifestyle modifications. 1, 2

Diagnosis and Confirmation

• Confirm hypertension using validated automated upper arm cuff devices with appropriate cuff size, taking at least two measurements per visit over multiple visits 1, 2
• Measure BP in both arms at first visit and use the higher reading 1, 2
• Confirm diagnosis with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before initiating treatment 1, 2
• Check standing BP in elderly patients and those with diabetes to assess for orthostatic hypotension 3, 1
• Note that home and ambulatory readings run approximately 10/5 mmHg lower than office readings 1

Immediate Treatment Indications

Initiate drug therapy without delay for:

• Malignant hypertension (severe hypertension with grade III-IV retinopathy) 3
• BP >220/120 mmHg 3
• BP ≥180/110 mmHg 2
• Impending complications such as transient ischemic attack or left ventricular failure 3

Lifestyle Modifications (For All Patients)

Dietary Interventions:

• Adopt a DASH diet emphasizing fruits, vegetables, whole grains, and low-fat dairy products, which reduces systolic BP by 5-8 mmHg 1, 4
• Restrict sodium to <2,300 mg/day (approximately 5-6 g salt), which reduces systolic BP by 2-8 mmHg 1, 2, 5
• Eliminate table salt use entirely 3
• Increase potassium intake through fruits and vegetables 1, 2

Alcohol Restriction:

• Men: limit to ≤2 standard drinks per day (maximum 14/week) 1, 2
• Women: limit to ≤1 standard drink per day (maximum 7-9/week) 1, 2
• Include alcohol-free days each week 3
• One standard drink = 14 g pure alcohol (12 oz beer, 5 oz wine, or 1.5 oz spirits) 1

Physical Activity:

• Minimum 150 minutes/week of moderate aerobic exercise (30 minutes on 5-7 days/week), which reduces systolic BP by 4-9 mmHg 1, 2, 4
• Add resistance training 2-3 times/week 1

Weight Management:

• Target BMI 20-25 kg/m² and waist circumference <102 cm (men) or <88 cm (women) 1, 2
• Each 1 kg weight loss reduces systolic BP by approximately 1 mmHg 1

Smoking Cessation:

• Complete smoking cessation with appropriate support is mandatory, as smoking risk outweighs BP benefits from medication 3, 2

Pharmacological Therapy Algorithm

For BP ≥160/100 mmHg:

• Initiate combination therapy immediately regardless of cardiovascular risk 3, 1, 2

For BP 140-159/90-99 mmHg:

• Initiate drug therapy immediately if target organ damage, established cardiovascular disease, diabetes, or 10-year cardiovascular disease risk ≥20% is present 3, 1
• For grade 1 hypertension without complications, evaluate lifestyle measures for up to 3-6 months before starting medications 3, 2, 5

Preferred Initial Combinations:

• ACE inhibitor (e.g., lisinopril) + dihydropyridine calcium channel blocker (e.g., amlodipine) 1, 2, 6, 7
• ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1, 2
• Calcium channel blocker + thiazide/thiazide-like diuretic 1, 2
• Use fixed-dose single-pill combinations to improve adherence 1, 2

Critical Pitfall to Avoid:

• Never combine two RAS blockers (ACE inhibitor + ARB) as this increases harm without additional benefit 1, 2

Blood Pressure Targets

Target BP varies by patient characteristics:

• Most adults <65 years: 120-129/70-79 mmHg 1, 2
• Adults ≥65 years: systolic <130 mmHg 1
• Patients with diabetes, CKD, or established CVD: ≤130/80 mmHg 3, 1, 2
• Minimum "audit standard" for all treated patients: <150/90 mmHg 3

Monitoring and Titration

• Schedule monthly visits until BP target is achieved (goal: within 3 months) 1, 2
• Utilize home BP monitoring to guide medication adjustments 1, 2
• Monitor serum creatinine and potassium 2-4 weeks after initiating or changing doses of ACE inhibitors, ARBs, or aldosterone antagonists 1, 2
• Once controlled, consider 90-day medication refills rather than 30-day to improve adherence 1
• Reassess BP and cardiovascular disease risk annually even in controlled patients 3

Special Populations

Elderly Patients:

• Initiate treatment at lower doses and titrate more gradually 2
• Monitor carefully for orthostatic hypotension 3, 1
• Consider treatment when office systolic BP ≥160 mmHg in patients >80 years 2

Black Patients:

• Initial therapy should include a calcium channel blocker with either a thiazide diuretic or a RAS blocker 2

Patients with Diabetes:

• Lower BP target of ≤130/80 mmHg is recommended 3, 1, 2
• Presence of microalbuminuria should lead to early treatment 3

Clinical Outcomes

• Effective BP control reduces stroke incidence by 35-40%, myocardial infarction by 20-25%, and heart failure by 50% 1
• For every 12 mmHg systolic BP reduction maintained over 10 years, one death is prevented for every 11 treated patients with additional cardiovascular risk factors 1
• An SBP reduction of 10 mmHg decreases risk of CVD events by approximately 20-30% 4

Common Pitfalls to Avoid

• Do not delay treatment in young adults with hypertension, as they have earlier onset of cardiovascular events 2
• Do not ignore lifestyle modifications even when starting medications, as they enhance medication efficacy and provide independent cardiovascular benefits 2, 5
• Do not withhold treatment due to asymptomatic orthostatic hypotension, as this is not associated with higher rates of cardiovascular events 2