What is the plan of care for a patient with hypertension?

Plan of Care for Hypertension

For most patients with confirmed hypertension (BP ≥140/90 mmHg), initiate combination therapy immediately with a RAS blocker (ACE inhibitor or ARB) plus a dihydropyridine calcium channel blocker or thiazide diuretic, preferably as a single-pill combination, targeting a systolic BP of 120-129 mmHg if well tolerated. 1

Initial Assessment and Diagnosis Confirmation

• Confirm hypertension diagnosis with multiple office readings, home BP monitoring (≥135/85 mmHg confirms hypertension), or 24-hour ambulatory monitoring (≥130/80 mmHg confirms hypertension) before initiating long-term therapy 1, 2
• Assess cardiovascular risk using 10-year ASCVD risk calculation, as this determines treatment intensity and BP targets 1
• Screen for target organ damage including left ventricular hypertrophy (ECG or echocardiogram), chronic kidney disease (creatinine, eGFR, urinalysis for proteinuria), and retinopathy (fundoscopic exam) 1, 2
• Evaluate for secondary causes if resistant hypertension develops, including primary aldosteronism (aldosterone-to-renin ratio), renal artery stenosis (renal ultrasound with Doppler), obstructive sleep apnea (sleep study), and pheochromocytoma (plasma or urine metanephrines) 1, 2

Blood Pressure Targets

• Target systolic BP of 120-129 mmHg for most adults if treatment is well tolerated, as this reduces cardiovascular risk most effectively 1
• For patients ≥65 years, target systolic BP <130 mmHg, with careful monitoring for orthostatic hypotension and adverse effects 1
• For patients with diabetes, target BP <130/80 mmHg to reduce cardiovascular and renal complications 1
• If BP targets cannot be safely achieved, apply the "as low as reasonably achievable" (ALARA) principle rather than abandoning treatment 1

Lifestyle Modifications (Mandatory for All Patients)

• Adopt Mediterranean or DASH diet with emphasis on vegetables, fruits, whole grains, lean proteins, and healthy fats to reduce BP and cardiovascular risk 1
• Restrict sodium intake to <2 g/day (approximately 5 g salt/day), which can lower BP by 5-10 mmHg 1, 2
• Achieve and maintain healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) through caloric restriction and increased physical activity 1
• Engage in aerobic exercise for at least 150 minutes/week of moderate-intensity activity, complemented with resistance training 2-3 times/week 1
• Limit alcohol consumption to <100 g/week of pure alcohol (approximately 7 standard drinks), or preferably avoid alcohol entirely for optimal health outcomes 1
• Eliminate sugar-sweetened beverages and restrict free sugar to maximum 10% of energy intake 1
• Stop tobacco smoking immediately and refer to smoking cessation programs, as tobacco independently causes cardiovascular disease and mortality 1

Pharmacological Treatment Algorithm

Initial Therapy for Most Patients (BP ≥140/90 mmHg)

• Start combination therapy immediately with two drugs from different classes, as monotherapy fails to achieve BP goals in up to 75% of patients 1, 3
• Preferred initial combinations include: 1
  • ACE inhibitor (e.g., lisinopril 10-20 mg) + dihydropyridine calcium channel blocker (e.g., amlodipine 5-10 mg), OR
  • ACE inhibitor + thiazide/thiazide-like diuretic (e.g., chlorthalidone 12.5-25 mg or indapamide 1.25-2.5 mg)
  • ARB (e.g., losartan 50-100 mg) can substitute for ACE inhibitor if not tolerated
• Use single-pill fixed-dose combinations whenever possible to improve adherence and BP control 1
• For Black patients specifically, initiate with calcium channel blocker + thiazide diuretic, as this combination is more effective than ACE inhibitor/ARB-based regimens in this population 4, 2

Exceptions to Combination Therapy

• Patients ≥85 years may start with monotherapy if frail or at high risk for adverse effects 1
• Patients with elevated BP (120-139/70-89 mmHg) and low-medium cardiovascular risk should receive lifestyle modifications for 3 months before considering pharmacotherapy 1
• Patients with elevated BP and high cardiovascular risk (≥10% 10-year risk) should start pharmacotherapy after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 1

Escalation to Triple Therapy

• If BP not controlled on two drugs, escalate to three-drug combination: RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 1
• Optimize doses of existing medications before adding a third agent 4, 2
• Reassess within 2-4 weeks after any medication adjustment 4, 2

Resistant Hypertension (Fourth-Line Therapy)

• Add spironolactone 25-50 mg daily as the preferred fourth agent if BP remains uncontrolled on optimized triple therapy 1, 4, 2
• Monitor serum potassium closely when combining spironolactone with ACE inhibitor or ARB due to hyperkalemia risk 1, 4
• Consider referral to hypertension specialist if BP remains ≥140/90 mmHg despite four-drug therapy at optimal doses 4, 2

Specific Drug Class Considerations

ACE Inhibitors and ARBs

• First-line for patients with diabetes, chronic kidney disease, heart failure with reduced ejection fraction, or post-myocardial infarction 1
• Monitor renal function and potassium 2-4 weeks after initiation and with dose changes 1, 4
• Never combine ACE inhibitor with ARB, as this increases adverse events without additional benefit 1, 4

Calcium Channel Blockers

• Dihydropyridines (amlodipine, nifedipine) are preferred for hypertension and can be combined with any other class 1, 5
• May reduce peripheral edema caused by calcium channel blockers when combined with ACE inhibitor or ARB 4

Thiazide and Thiazide-Like Diuretics

• Chlorthalidone or indapamide preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes 1, 4, 6
• Monitor for hypokalemia, hyperuricemia, and glucose intolerance 4

Beta-Blockers

• Reserve for specific indications: angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control 1
• Not recommended as first-line monotherapy for uncomplicated hypertension 1

Medication Timing and Adherence

• Take medications at the most convenient time to establish habitual pattern and improve adherence, rather than mandating specific timing 1
• Use once-daily dosing and single-pill combinations to maximize adherence 1
• Assess adherence at every visit, as non-adherence accounts for approximately 40% of apparent treatment failure 2

Monitoring and Follow-Up

• Recheck BP within 1 month for patients with BP 130-159/80-99 mmHg 1
• Initiate treatment immediately for BP ≥160/100 mmHg without waiting for confirmation 1
• Reassess within 2-4 weeks after any medication adjustment 4, 2
• Achieve target BP within 3 months of initiating or modifying therapy 1, 4, 2
• Monitor for orthostatic hypotension especially in elderly patients and those on multiple medications 1
• Continue BP-lowering therapy lifelong, even beyond age 85 years, if well tolerated 1

Common Pitfalls to Avoid

• Do not delay treatment intensification when BP remains above target, as therapeutic inertia increases cardiovascular risk 4
• Verify medication adherence before labeling as resistant hypertension, using pill counts, pharmacy refill records, or direct questioning 2
• Discontinue or minimize interfering substances including NSAIDs, decongestants, stimulants, and excessive alcohol before escalating therapy 1, 2
• Rule out white coat hypertension with home or ambulatory monitoring before intensifying treatment 2
• Do not use beta-blockers as monotherapy for uncomplicated hypertension without compelling indications 1

Special Populations

Patients with Diabetes

• Target BP <130/80 mmHg to reduce cardiovascular and microvascular complications 1
• Prefer ACE inhibitors or ARBs especially if albuminuria or renal insufficiency present 1

Elderly Patients (≥65 years)

• Target systolic BP <130 mmHg for community-dwelling, ambulatory adults 1
• Monitor carefully for orthostatic hypotension, falls, and adverse effects 1
• For high comorbidity burden and limited life expectancy, use clinical judgment and shared decision-making for treatment intensity 1

Pregnant Patients with Severe Preeclampsia/Eclampsia

• Target BP <160/105 mmHg to prevent maternal complications 1
• Use labetalol or nicardipine intravenously if urgent BP lowering needed 1
• Avoid cumulative labetalol >800 mg/24h to prevent fetal bradycardia 1
• Never use nitroprusside due to risk of fetal cyanide toxicity 1