What is the best treatment approach for a patient with hypertension?

Treatment Approach for Hypertension

For most patients with hypertension, initiate lifestyle modifications immediately and start pharmacological therapy with a first-line agent (ACE inhibitor, ARB, thiazide/thiazide-like diuretic, or dihydropyridine calcium channel blocker), with consideration for two-drug combination therapy if blood pressure is ≥20/10 mmHg above target. 1

Initial Assessment and Blood Pressure Confirmation

• Confirm hypertension diagnosis using a validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at first visit and using the arm with higher readings for subsequent measurements 2
• Hypertension is defined as office BP ≥140/90 mmHg, confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 2
• Assess for target organ damage (cardiac, renal, neurologic), cardiovascular risk factors, and screen for secondary causes of hypertension 2, 3

Lifestyle Modifications (Initiate for All Patients)

• Weight management: Implement caloric restriction for overweight/obese patients 2
• DASH dietary pattern: Reduce sodium intake to <2,300 mg/day, increase potassium intake with 8-10 servings of fruits and vegetables daily, and consume low-fat dairy products 2, 4
• Physical activity: Engage in at least 150 minutes of moderate-intensity aerobic activity per week 2, 5
• Alcohol limitation: No more than 2 servings per day for men and 1 serving per day for women 2
• Smoking cessation: Complete cessation for all smokers 2

The DASH diet alone has effects equal to single drug therapy, and lifestyle modifications are partially additive with pharmacologic therapy 6, 4

Pharmacological Therapy Algorithm

Step 1: Initial Drug Selection

First-line options include: 2, 6

• ACE inhibitors (e.g., lisinopril) 2, 7
• Angiotensin receptor blockers (ARBs) 2
• Thiazide/thiazide-like diuretics 2, 6
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 2, 6

Race-specific considerations:

• For Black patients, start with ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic 2
• For non-Black patients, any first-line agent is appropriate 8

Special populations:

• ACE inhibitor or ARB is preferred for patients with albuminuria (UACR ≥30 mg/g) or established coronary artery disease 2
• For patients >80 years or frail, consider starting with monotherapy at lower doses 2

Step 2: Two-Drug Combination Therapy

Initiate with two agents if BP is >20/10 mmHg above target (typically BP ≥160/100 mmHg for a target of <140/90 mmHg) 1, 2

• Fixed-dose combination products show greater BP lowering than single agents and better adherence 1
• Consider once-daily dosing and single-pill combinations to improve adherence 8, 9
• Caution in older patients: Monitor carefully for hypotension or orthostatic hypotension 1

Step 3: Medication Titration and Addition

If BP remains uncontrolled:

• Increase ARB to maximum tolerated dose before adding additional agents 8
• Add a dihydropyridine calcium channel blocker as second agent for non-Black patients 8
• Add either DHP-CCB or thiazide/thiazide-like diuretic as second agent for Black patients 8
• Add a thiazide/thiazide-like diuretic as third agent if not already included 8
• Allow 2-4 weeks for full effect of dose adjustments before further changes 8

Step 4: Resistant Hypertension (Four-Drug Regimen)

If BP remains uncontrolled on three agents:

• Add spironolactone as the preferred fourth-line agent 8
• Alternatives include amiloride, clonidine, or beta-blocker 8
• Refer to hypertension specialist if BP remains uncontrolled despite adherence to four-drug regimen including a diuretic 8

Blood Pressure Targets and Monitoring

• Target BP: <130/80 mmHg for most adults <65 years; <130 mmHg systolic for adults ≥65 years 6
• For elderly patients with multiple comorbidities, individualize target to 140/90 mmHg based on frailty status 9
• Home BP monitoring target: <135/85 mmHg 9
• Aim to achieve target BP within 3 months of treatment initiation 8, 2
• Check BP within 4 weeks of any medication adjustment 9
• Monitor serum creatinine and potassium 7-14 days after initiation or dose changes for patients on ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2

Common Pitfalls to Avoid

• Not checking medication adherence before adding additional agents—this is a common cause of inadequate BP control 8
• Inadequate dosing of medications before adding new agents 8
• Not allowing sufficient time (2-4 weeks) for full effect of dose adjustments before further changes 8
• Combining ACE inhibitors and ARBs—not recommended due to increased risk of adverse effects without additional benefit 2
• Treating asymptomatic elevated inpatient BP too aggressively—focus on controlling underlying stressors rather than aggressive BP lowering 2

Team-Based Care Approach

For patients requiring 2-3 medications or more who do not respond or tolerate treatment, team-based care may be effective in achieving BP control 1. Approximately 25-50% of patients will achieve BP control with initial therapy, while 25% will require additional treatment adjustments 1.