What is the step-by-step treatment protocol for hypertension?

Hypertension Treatment Protocol: Step-by-Step Algorithm

Step 1: Confirm Diagnosis and Measure Baseline Blood Pressure

Hypertension is defined as office BP ≥140/90 mmHg, but must be confirmed with out-of-office measurements before initiating treatment. 1

• Measure BP in both arms using a validated automated upper arm cuff device with appropriate cuff size, and use the higher reading for subsequent measurements 1, 2
• Confirm diagnosis with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 1, 2
• Assess for target organ damage (left ventricular hypertrophy, retinopathy, proteinuria), cardiovascular risk factors, diabetes, chronic kidney disease, and secondary causes of hypertension 1

Step 2: Initiate Lifestyle Modifications for ALL Patients

All patients with confirmed hypertension must implement lifestyle modifications regardless of whether drug therapy is started. 1, 3

• Dietary changes: Implement DASH or Mediterranean diet with sodium restriction to <2g/day, increased potassium intake, and low-fat dairy products 1, 3
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly plus resistance training 2-3 times per week 1
• Weight management: Achieve and maintain healthy body mass index through weight loss if overweight 3, 4
• Alcohol moderation: Limit to ≤2 standard drinks per day (maximum 14/week for men, 9/week for women) 1, 5
• Smoking cessation: Complete abstinence from tobacco 1

These lifestyle modifications can reduce BP by 10-20 mmHg and are complementary to pharmacotherapy—never discontinue them once drug therapy starts. 1, 3

Step 3: Determine When to Start Pharmacological Therapy

For Grade 2 Hypertension (≥160/100 mmHg), start drug treatment immediately in all patients. 2

For Grade 1 Hypertension (140-159/90-99 mmHg), start drug treatment immediately if the patient has any of the following: 2

• Established cardiovascular disease
• Chronic kidney disease
• Diabetes mellitus
• Target organ damage
• Age 50-80 years

Step 4: Select Initial Pharmacological Therapy (Race-Specific)

The preferred initial approach is two-drug combination therapy as a single-pill combination, NOT sequential monotherapy. 1

For Non-Black Patients:

Start with low-dose ACE inhibitor or ARB + dihydropyridine calcium channel blocker (DHP-CCB). 1, 2

For Black Patients:

Start with low-dose ARB + DHP-CCB OR DHP-CCB + thiazide-like diuretic. 1, 2

Rationale: This combination approach targets different mechanisms (renin-angiotensin system blockade and vasodilation) and is more effective than sequential monotherapy titration. 1

Step 5: Titrate to Target Blood Pressure

Target BP is <130/80 mmHg for most adults, including those with diabetes, CKD, or established CVD. 1, 3

Initial goal: Reduce BP by at least 20/10 mmHg within 3 months of initiating treatment. 1, 2

Titration Schedule:

• Schedule follow-up within 2-4 weeks initially to assess response and tolerability 1, 2
• Check serum creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Achieve target BP within 3 months of treatment initiation 1, 2

Step 6: Add Third Agent if BP Remains Uncontrolled

If BP remains above target after optimizing the initial two-drug combination, add a thiazide or thiazide-like diuretic as the third agent. 1, 2

For Non-Black Patients:

• Sequence: ACE inhibitor/ARB + DHP-CCB → optimize doses → add thiazide/thiazide-like diuretic 2
• Preferred diuretic: Chlorthalidone 12.5-25mg daily (longer duration of action than hydrochlorothiazide) 6

For Black Patients:

• If started on ARB + DHP-CCB, add thiazide/thiazide-like diuretic 2
• If started on DHP-CCB + thiazide diuretic, add ARB 2

This triple therapy combination (RAS blocker + CCB + thiazide diuretic) represents guideline-recommended treatment for uncontrolled hypertension. 6

• Monitor serum potassium and creatinine 2-4 weeks after initiating diuretic therapy to detect hypokalemia or changes in renal function 6

Step 7: Manage Resistant Hypertension (Fourth-Line Agent)

If BP remains uncontrolled (≥140/90 mmHg) despite optimized triple therapy, add spironolactone 25-50mg daily as the preferred fourth-line agent. 1, 2, 6

Before Adding Fourth Agent:

• Confirm medication adherence (non-adherence is the most common cause of apparent treatment resistance) 6
• Rule out secondary causes of hypertension 6
• Verify adequate lifestyle modifications, especially sodium restriction to <2g/day 6

Alternative Fourth-Line Agents (if spironolactone contraindicated or not tolerated):

• Amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 2

Monitor potassium closely when adding spironolactone to an ACE inhibitor or ARB, as hyperkalemia risk is significant. 6

Step 8: Referral for Specialist Management

Refer to a hypertension specialist if: 6

• BP remains uncontrolled (≥160/100 mmHg) despite four-drug therapy at optimal doses
• Multiple drug intolerances occur
• Concerning features suggesting secondary hypertension are identified

Critical Pitfalls to Avoid

NEVER combine two RAS blockers (ACE inhibitor + ARB) as this is potentially harmful without additional benefit. 1, 6

Avoid clinical inertia: Immediate combination therapy is more effective than sequential monotherapy titration—do not delay intensification. 1, 6

Do not add a third drug class before maximizing doses of the current two-drug regimen—this violates guideline-recommended stepwise approaches and exposes patients to unnecessary polypharmacy. 6

Do not discontinue lifestyle modifications once drug therapy starts—they provide additive BP reduction of 10-20 mmHg and may reduce medication requirements. 1, 6

For Black patients specifically, the combination of CCB + thiazide diuretic may be more effective than CCB + ARB, so consider this when selecting initial therapy. 1, 6

Special Population Considerations

Patients with Coronary Artery Disease:

• Consider RAS blockers and beta-blockers with or without CCBs 2

Patients with Heart Failure:

• Consider RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 2

Patients with Chronic Kidney Disease:

• Prefer ACE inhibitors or ARBs 2

Patients with Previous Stroke:

• Consider RAS blockers, CCBs, and diuretics 2

Patients with Diabetes:

• Prefer ACE inhibitors or ARBs (or thiazides/DHP-CCBs in patients without albuminuria) 2