What are the steps for managing a diagnosis of hypertension?

Step-by-Step Management of Newly Diagnosed Hypertension

For most patients with confirmed hypertension, initiate combination therapy with a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide-like diuretic as first-line treatment, preferably as a fixed-dose single-pill combination. 1

Step 1: Confirm the Diagnosis

• Measure BP using a validated automated upper arm cuff device with appropriate cuff size for the patient 2
• At the first visit, measure BP in both arms simultaneously and use the arm with higher readings for subsequent measurements 2
• Hypertension is confirmed when office BP ≥140/90 mmHg 2, 1
• Verify the diagnosis with out-of-office monitoring: home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 2, 1
• Take the average of multiple readings (at least 2 measurements at each of several visits) before making treatment decisions 2

Common pitfall: White coat hypertension can lead to overdiagnosis—always confirm with home or ambulatory monitoring before starting lifelong therapy 2

Step 2: Perform Initial Assessment

Routine investigations to perform:

• Urine dipstick for blood and protein 2
• Serum electrolytes, creatinine, and calculate eGFR 2
• Fasting blood glucose 2
• Serum total cholesterol and HDL cholesterol ratio 2
• 12-lead electrocardiogram 2
• Thyroid-stimulating hormone (TSH) 2

Assess cardiovascular risk factors:

• Target organ damage (left ventricular hypertrophy, retinopathy, proteinuria, elevated creatinine) 2
• Existing cardiovascular disease, chronic kidney disease, or diabetes 2
• 10-year cardiovascular disease risk calculation 2
• Age (particularly if 50-80 years) 2

Screen for secondary hypertension if:

• Age <30 years without typical risk factors 2
• Resistant hypertension (uncontrolled on 3+ drugs) 2
• Sudden deterioration in BP control 2
• Serum potassium <3.5 mmol/L (suggests primary aldosteronism) 2

Step 3: Initiate Lifestyle Modifications (For ALL Patients)

Start these immediately, regardless of whether drug therapy is initiated: 2

• Weight management: Achieve BMI 20-25 kg/m² through caloric restriction if overweight 1
• Dietary pattern: Follow DASH or Mediterranean diet 1
• Sodium restriction: Reduce intake to <2,300 mg/day (<100 mmol/day) 1, 3
• Potassium supplementation: Increase dietary potassium intake 1, 3
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise per week 1, 3
• Alcohol limitation: <100g/week of pure alcohol (approximately 7 standard drinks per week; maximum 14/week for men, 9/week for women) 1, 4
• Smoking cessation: Complete abstinence 1

Expected BP reduction: These lifestyle modifications can lower BP by 4-11 mmHg systolic when implemented together 3

Step 4: Determine When to Start Drug Therapy

Start drug therapy IMMEDIATELY (do not wait) if:

• High-risk patients: those with CVD, CKD, diabetes, target organ damage, or aged 50-80 years 2
• BP ≥160/100 mmHg (Grade 2-3 hypertension) 2, 1

Start drug therapy after 3-6 months of lifestyle intervention if:

• Low-moderate risk patients with persistent BP elevation ≥140/90 mmHg despite lifestyle changes 2

Critical point: Do not delay treatment in young adults with hypertension—they have earlier onset of cardiovascular events compared to those with normal BP 1

Step 5: Select Initial Drug Therapy

For Non-Black Patients:

First-line combination (preferred): 2, 1

• RAS blocker (ACE inhibitor like lisinopril OR ARB like losartan) PLUS
• Either dihydropyridine calcium channel blocker (amlodipine) OR thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide)

Start with low doses in combination, preferably as a single-pill fixed-dose combination 2

For Black Patients:

First-line combination: 2

• ARB (not ACE inhibitor) PLUS dihydropyridine calcium channel blocker
• OR dihydropyridine calcium channel blocker PLUS thiazide-like diuretic

Rationale: ACE inhibitors and ARBs have smaller BP effects as monotherapy in Black patients 5, 6

Special Considerations:

Monotherapy may be considered only for: 2

• Low-risk patients with Grade 1 hypertension (140-159/90-99 mmHg)
• Patients aged >80 years
• Frail elderly patients

Avoid these combinations: 1

• ACE inhibitor + ARB together (potentially harmful)
• Beta-blocker + thiazide diuretic as first-line (dysmetabolic effects, increased diabetes risk) 2

Step 6: Titrate to Target BP

Blood Pressure Targets:

For most adults <65 years: 1

• Target: 120-129/70-79 mmHg (optimal)
• Minimum acceptable: <140/90 mmHg 2

For adults ≥65 years: 1, 3

• Target: SBP <130 mmHg
• Individualize based on frailty 2

For patients with diabetes or CKD: 2

• Target: <130/80 mmHg

Titration Algorithm:

If BP not controlled on 2-drug combination: 2, 1

1. Increase doses to full therapeutic doses
2. Add third drug: complete the triple therapy with RAS blocker + calcium channel blocker + thiazide-like diuretic

If BP not controlled on 3-drug combination (resistant hypertension): 2

1. First exclude pseudoresistance: poor measurement technique, white coat effect, medication nonadherence, suboptimal drug choices
2. Optimize diuretic therapy (use thiazide-like rather than thiazide; switch to loop diuretic if eGFR <30 mL/min/1.73m²) 2
3. Add spironolactone 25-50 mg/day as 4th agent if serum potassium <4.5 mmol/L and eGFR >45 mL/min/1.73m² 2
4. If spironolactone contraindicated: use amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 2

Timeline: Achieve target BP within 3 months of starting therapy 2, 1

Step 7: Monitor Treatment

Initial monitoring (2-4 weeks after starting or changing therapy): 1

• Serum creatinine and potassium (especially with ACE inhibitors, ARBs, or aldosterone antagonists)
• BP measurement (office and home)

Ongoing monitoring:

• BP control assessment every 1-3 months until target achieved 2
• Home BP monitoring to guide medication adjustments 1
• Annual assessment of adherence, side effects, and cardiovascular risk factors 2

Common pitfall: Do not withhold or down-titrate treatment due to asymptomatic orthostatic hypotension—this is not associated with higher rates of cardiovascular events 1

Step 8: Address Treatment Failure

If BP remains uncontrolled despite 3+ drugs:

Assess for causes of resistant hypertension: 2

• Medication nonadherence (most common cause) 2
• Suboptimal drug regimen or inadequate doses 2
• Volume overload (insufficient diuretic therapy, excessive salt intake, progressing renal insufficiency) 2
• Obstructive sleep apnea 2
• Secondary hypertension (primary aldosteronism, renovascular disease, renal parenchymal disease) 2
• Drug/substance-induced hypertension (NSAIDs, decongestants, alcohol, cocaine, licorice) 2
• White coat effect (confirm with ambulatory monitoring) 2

Refer to specialist center with hypertension expertise if BP remains uncontrolled or secondary hypertension suspected 2

Strategies to improve adherence: 2

• Simplify regimen with once-daily dosing and single-pill combinations 2
• Provide clear written and oral instructions 2
• Address side effects promptly and adjust medications if needed 2
• Involve family members in treatment plan 2
• Discuss adherence at every visit 2

Key benefit: Every 10 mmHg reduction in systolic BP decreases cardiovascular events by 20-30% 3