What are the initial management and treatment options for Hypertension (Htn)?

Initial Management and Treatment of Hypertension

For adults with confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications and pharmacologic therapy simultaneously—do not delay medication while attempting lifestyle changes alone. 1

Confirming the Diagnosis

• Confirm hypertension using out-of-office measurements before starting treatment: home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 2
• Measure BP in both arms at the first visit and use the arm with higher readings for subsequent measurements 2

Lifestyle Modifications (For All Patients with BP >120/80 mmHg)

Implement the following evidence-based lifestyle interventions, which lower BP and enhance medication effectiveness: 3

• Weight management: Achieve and maintain healthy body weight through caloric restriction if overweight 3, 1
• DASH eating pattern: 3, 1
  • Fruits and vegetables: 8-10 servings daily 3, 1
  • Low-fat dairy products: 2-3 servings daily 3, 1
  • Reduced saturated and trans fats 3
• Sodium restriction: Limit intake to <2,300 mg/day 3, 1
• Increased potassium intake: Through dietary sources 1
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity weekly 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 3, 1
• Smoking cessation: For all patients 1

Pharmacologic Therapy Algorithm

BP 140/90 to 159/99 mmHg (Stage 1)

Start with a single antihypertensive agent from first-line classes: 3, 1

• First-line options: ACE inhibitor, ARB, thiazide-like diuretic, or dihydropyridine calcium channel blocker 3, 4
• Specific example: Lisinopril 10 mg once daily is an appropriate starting dose 1, 5
• For Black patients: Prefer ARB or calcium channel blocker over ACE inhibitor as monotherapy due to reduced response 1

BP ≥160/100 mmHg (Stage 2)

Initiate combination therapy with two antihypertensive agents from different classes, preferably as a single-pill combination: 3, 1

• Recommended combinations: 1
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker, OR
  • RAS blocker + thiazide/thiazide-like diuretic
• Specific example: Chlorthalidone 12.5-25 mg daily plus lisinopril 10 mg daily 1
• Rationale: Two-drug therapy achieves BP control faster, improves adherence, and reduces cardiovascular risk more rapidly than sequential monotherapy 1

Note: Chlorthalidone is preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes data 1

Special Population Considerations

Diabetes or Chronic Kidney Disease

• Use ACE inhibitor or ARB as first-line therapy 3, 2
• For albuminuria (UACR ≥30 mg/g), ACE inhibitor or ARB at maximum tolerated dose is mandatory to reduce progressive kidney disease 3

Coronary Artery Disease

• ACE inhibitors or ARBs are recommended as first-line therapy 3
• Beta-blockers are indicated only with prior MI, active angina, or heart failure with reduced ejection fraction 3

Pregnancy or Women Planning Pregnancy

• Absolute contraindications: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors due to fetal injury and death 1, 2

Black Patients

• Initial therapy should include: ARB + dihydropyridine calcium channel blocker, OR calcium channel blocker + thiazide/thiazide-like diuretic 1, 2

Medication Titration Strategy

• If BP not controlled on single agent: Increase to maximum tolerated dose before adding a second agent 1
• Lisinopril titration: Can increase from 10 mg to 20-40 mg daily (usual range 20-40 mg/day) 1, 5
• If BP not controlled on two agents: Add a third drug from a different class (typically completing the ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic combination) 1

Blood Pressure Targets

• Adults <65 years: <130/80 mmHg 1, 2, 4
• Adults 65-85 years: Systolic BP 120-129 mmHg if well tolerated 1, 2
• CKD patients (eGFR >30 mL/min/1.73m²): Systolic BP 120-129 mmHg 2

Monitoring and Follow-Up

• Initial follow-up: Recheck BP within 1 month after initiating or changing therapy 1
• Goal timeline: Achieve BP control within 3 months 1, 2
• Laboratory monitoring: Check serum creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 3, 2
• Ongoing monitoring: At least annually for patients on ACE inhibitors, ARBs, or diuretics 3

Resistant Hypertension (BP ≥140/90 mmHg on Three Drugs)

Resistant hypertension is defined as BP ≥140/90 mmHg despite appropriate lifestyle management plus a diuretic and two other antihypertensive drugs at adequate doses. 3

• Before diagnosing resistant hypertension, exclude: Medication nonadherence, white coat hypertension, and secondary hypertension 3
• Standard three-drug combination: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 1
• Fourth-line agent: Add spironolactone 25 mg daily if BP remains uncontrolled 3, 1

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with BP ≥140/90 mmHg 1
• Avoid combining ACE inhibitors with ARBs or using ACE inhibitor/ARB with direct renin inhibitors due to increased risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 3
• Do not use beta-blockers as initial therapy unless specific indications exist (heart failure, coronary disease, prior MI) 3, 1
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics are preferred 1
• Do not use ACE inhibitors in patients with history of angioedema 1
• Avoid ACE inhibitors/ARBs in severe bilateral renal artery stenosis due to acute renal failure risk 1