What are the recommended treatments for managing hypertension?

Hypertension Management

Immediate Treatment Approach

For most adults with confirmed hypertension (BP ≥140/90 mmHg), start immediately with combination therapy using two first-line agents—specifically a RAS blocker (ACE inhibitor or ARB) combined with either a calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1, 2

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Diagnostic Confirmation

Before initiating treatment, confirm hypertension with proper measurement technique:

• Use a validated device with the patient seated, arm at heart level, taking at least two readings per visit 1, 2
• Consider ambulatory blood pressure monitoring if you suspect white coat hypertension, observe unusual BP variability, or encounter resistant hypertension 2
• Calculate 10-year cardiovascular disease risk to guide treatment intensity, particularly for borderline hypertension (130-139/80-89 mmHg) 1, 2

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Lifestyle Modifications (Foundation for All Patients)

Implement these evidence-based interventions alongside pharmacotherapy:

Weight Management

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1, 2

Physical Activity

• Minimum 150 minutes/week of moderate-intensity aerobic activity OR 75 minutes/week of vigorous activity 1, 2
• Add resistance training 2-3 times weekly 1, 2

Dietary Modifications

• Reduce sodium intake (avoid table salt) 2
• Increase consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids 2
• Restrict free sugar to maximum 10% of energy intake 2

Alcohol and Smoking

• Men: <14 units/week; Women: <8 units/week 2
• Complete smoking cessation 2

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Pharmacological Treatment Algorithm

Step 1: Initial Dual Therapy

• Start with RAS blocker (lisinopril 3 or losartan 4) PLUS either:
  • Dihydropyridine calcium channel blocker (e.g., amlodipine) 1, 2, 5
  • OR thiazide/thiazide-like diuretic (e.g., chlorthalidone, hydrochlorothiazide) 1, 2, 5
• Use single-pill fixed-dose combinations to improve adherence 1, 2
• Begin at low doses 1

Step 2: Triple Therapy (if BP uncontrolled after 4 weeks)

• Escalate to RAS blocker + CCB + thiazide/thiazide-like diuretic 1, 2
• Again, preferably as a single-pill combination 1, 2

Step 3: Resistant Hypertension

• Add spironolactone as fourth-line therapy 2

Critical Pitfall

• Never combine two RAS blockers (ACE inhibitor + ARB) together—this increases adverse effects without additional benefit 1, 2

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Blood Pressure Targets

Standard Adult Targets (Age <65 years)

• Target systolic BP 120-129 mmHg and diastolic BP <80 mmHg if well tolerated 1, 2

Older Adults (Age ≥65 years)

• Target systolic BP 130-139 mmHg 1, 2

Very Elderly or Frail (Age ≥85 years or symptomatic orthostatic hypotension)

• Consider more lenient target <140/90 mmHg 2

High-Risk Patients (Diabetes, CKD, Established CVD)

• Target <130/80 mmHg 1, 2

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Special Population Considerations

Black Patients

• Initial therapy should include a thiazide-like diuretic plus CCB, or CCB plus ARB 1, 2
• Note: Losartan's stroke reduction benefit in left ventricular hypertrophy does not apply to Black patients 4

Coronary Artery Disease

• Target BP <130/80 mmHg 1
• Use RAS blockers and beta-blockers as first-line agents 1

Heart Failure with Reduced Ejection Fraction

• Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1, 2
• Consider ARNI (sacubitril/valsartan) as alternative to ACE inhibitor/ARB 1

Heart Failure with Preserved Ejection Fraction

• Consider SGLT2 inhibitors 2

Previous Stroke/TIA

• Target systolic BP 120-130 mmHg 1, 2
• Use RAS blockers, CCBs, and diuretics as first-line agents 1

Chronic Kidney Disease

• Include RAS blocker when albuminuria/proteinuria is present 1, 2
• Target systolic BP 120-129 mmHg for eGFR >30 mL/min/1.73m² 1, 2
• Losartan specifically reduces progression of diabetic nephropathy (doubling of serum creatinine or end-stage renal disease) in type 2 diabetics with elevated creatinine and proteinuria 4

Diabetes

• Initiate treatment at BP ≥140/90 mmHg 1
• Target BP <130/80 mmHg 1, 2

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Monitoring and Long-Term Management

• Use both office and home BP readings for regular monitoring 1, 2
• Reassess cardiovascular risk annually 1, 2
• Continue lifelong BP-lowering treatment if well tolerated, even beyond age 85 1, 2
• Employ multidisciplinary team approaches involving pharmacists to enhance adherence 1

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Common Pitfalls to Avoid

• Failing to confirm elevated readings with multiple measurements before diagnosis 2
• Not considering white coat hypertension when office readings are elevated 2
• Inadequate dosing or using inappropriate medication combinations 2
• Neglecting lifestyle modifications alongside pharmacological treatment 2
• Using overly lenient BP targets in high-risk patients 2
• Starting with monotherapy instead of combination therapy in confirmed hypertension 1, 2