What are the management steps for Hypertension (High Blood Pressure)?

From the Guidelines

Hypertension management involves a stepwise approach starting with lifestyle modifications for all patients, as recommended by the most recent guidelines 1. These lifestyle modifications include reducing sodium intake to less than 2.3g daily, following the DASH diet rich in fruits and vegetables, regular physical activity (150 minutes of moderate exercise weekly), limiting alcohol consumption, maintaining healthy weight, and smoking cessation. The importance of lifestyle modifications is emphasized in several studies, including those from 2003 1, 2022 1, 2020 1, and 2018 1, which all support the role of lifestyle changes in managing hypertension. If blood pressure remains above 140/90 mmHg despite lifestyle changes, medication therapy should begin, with first-line medications including thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers, as suggested by guidelines from 2007 1 and 2022 1. Treatment typically starts with a single agent at a low dose, increasing as needed, and may involve the addition of multiple medications for adequate control, with the goal of achieving a blood pressure below 130/80 mmHg, as recommended by the 2022 guidelines 1. Regular monitoring, including home blood pressure measurements, is essential for managing hypertension, and the choice of medication should be individualized based on the patient's specific needs and comorbidities, considering the mechanisms of action of different medications, such as diuretics reducing fluid volume, ACE inhibitors and ARBs blocking the renin-angiotensin system, and calcium channel blockers relaxing blood vessel walls, as discussed in the 2007 guidelines 1. Key points to consider in hypertension management include:

• Lifestyle modifications as the foundation of treatment
• The use of first-line medications such as thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers
• The importance of regular monitoring and individualized treatment goals
• The potential need for multiple medications to achieve adequate blood pressure control
• Consideration of the patient's overall health and comorbidities in treatment decisions.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

The main steps for hypertension management include:

• Comprehensive cardiovascular risk management
• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake
• Using more than one drug to achieve blood pressure goals if necessary, as stated in the losartan label 2 and the lisinopril label 3. It is recommended to follow published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), for specific advice on goals and management.

From the Research

Hypertension Management Steps

• Lifestyle modifications are associated with improvements in blood pressure, including:
  • Dietary Approaches to Stop Hypertension diet 4
  • Sodium restriction 4, 5
  • Regular exercise 4, 5, 6
  • Moderate weight loss 4, 5
  • Potassium enrichment 5
  • Moderation of alcohol consumption 5
  • Stress management 6
  • Promotion of adequate sleep patterns coupled with circadian entrainment 6
• Blood pressure goals:
  • Less than 140/90 mm Hg in patients with chronic kidney disease and in those with diabetes mellitus 4
  • Less than 140/90 mm Hg to reduce the risk of all-cause and cardiovascular mortality in adults with hypertension 5
  • Less than 135/85 mm Hg may further reduce the risk of myocardial infarction 5
  • Less than 150 mm Hg in adults older than 60 years, although evidence in younger adults is insufficient to recommend a specific goal 4
• Antihypertensive medications:
  • First-line medications include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics 4, 5
  • Thiazide diuretics and calcium channel blockers are preferred in black patients 4
  • Beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and in the case of heart failure, aldosterone antagonists are appropriate for patients with coronary artery disease 7

Combination Therapy

• Combination therapy is recommended for patients who cannot achieve blood pressure targets with monotherapy 8
• The most frequently prescribed combinations include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and calcium channel blockers 8
• The prescription of combination therapy differs from recommended combinations by the wider use of drugs from the beta-blocker group 8