Hypertension Management
For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate combination pharmacological therapy immediately with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic as a single-pill combination, while simultaneously implementing comprehensive lifestyle modifications. 1, 2
Blood Pressure Targets
Target systolic BP of 120-129 mmHg for most adults under 65 years if well tolerated 1, 2. This represents the most current evidence-based target that reduces cardiovascular events and mortality. For adults ≥65 years, target systolic BP 130-139 mmHg 2, 3. If the 120-129 mmHg target is poorly tolerated, apply the "as low as reasonably achievable" (ALARA) principle 1.
For high-risk patients (diabetes, chronic kidney disease, established cardiovascular disease), target BP <130/80 mmHg 2, 3.
Pharmacological Treatment Algorithm
Initial Therapy (BP ≥140/90 mmHg)
Start with two-drug combination therapy immediately rather than monotherapy, as this achieves better BP control 1, 2:
- Preferred combinations: RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker OR RAS blocker + thiazide/thiazide-like diuretic (chlorthalidone or indapamide) 1, 2, 3
- Prescribe as single-pill fixed-dose combination to improve adherence 1, 2, 3
- Exceptions to combination therapy: Patients ≥85 years, symptomatic orthostatic hypotension, moderate-to-severe frailty, or elevated BP (120-139/70-89 mmHg) with low cardiovascular risk 1
Escalation to Triple Therapy
If BP remains uncontrolled after 4 weeks on dual therapy, escalate to RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1, 2, 3.
Resistant Hypertension (Fourth-Line)
Add spironolactone when BP remains uncontrolled on triple therapy 3.
First-Line Drug Classes
ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and thiazides/thiazide-like diuretics have demonstrated the most effective reduction in BP and cardiovascular events 1. These are FDA-approved for hypertension treatment and reduce risk of stroke, myocardial infarction, and cardiovascular mortality 4, 5.
Beta-Blockers
Reserve beta-blockers for compelling indications: angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control 1. Combine with other major BP-lowering drug classes when indicated 1.
Lifestyle Modifications (Essential for All Patients)
Weight Management
- Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1, 2
- Weight loss reduces BP and cardiovascular risk even without achieving ideal BMI 6, 7
Physical Activity
- Minimum 150 minutes/week of moderate-intensity aerobic exercise (or 75 minutes/week vigorous intensity) 2, 3
- Add resistance training 2-3 times weekly (low to moderate intensity, dynamic or isometric) 1, 2
Dietary Modifications
- Adopt Mediterranean or DASH diet patterns 1
- Restrict sodium intake: avoid table salt and processed foods 1, 3, 6
- Increase potassium intake through fruits and vegetables 6, 7
- Limit free sugar to maximum 10% of energy intake; avoid sugar-sweetened beverages 1, 3
Alcohol Restriction
- Men: <100 g/week of pure alcohol (approximately 7-12 standard drinks depending on portion size) 1
- Women: lower limits recommended 1
- Preferably avoid alcohol completely for best health outcomes 1
Smoking Cessation
- Complete tobacco cessation is mandatory as smoking independently causes cardiovascular disease and mortality 1, 3
- Initiate supportive care and refer to cessation programs 1
Special Population Considerations
Black Patients
Initial therapy should include a thiazide-like diuretic plus calcium channel blocker, or calcium channel blocker plus ARB 2. Note that some antihypertensive drugs have smaller BP effects as monotherapy in Black patients 4, 5, 6.
Chronic Kidney Disease
- Include RAS blocker when albuminuria/proteinuria is present 2, 3
- Target systolic BP 120-129 mmHg for eGFR >30 mL/min/1.73m² 2, 3
Diabetes
- Initiate treatment at BP ≥140/90 mmHg 2, 3
- Target BP <130/80 mmHg 2, 3
- Losartan specifically reduces progression of diabetic nephropathy (doubling of serum creatinine, end-stage renal disease) in type 2 diabetes with proteinuria 4
Heart Failure
- HFrEF: Use ACE inhibitor/ARB, beta-blocker, diuretic, and/or mineralocorticoid receptor antagonist 2, 3
- HFpEF: Consider SGLT2 inhibitors 3
Previous Stroke/TIA
- Target systolic BP 120-130 mmHg 2, 3
- Use RAS blockers, calcium channel blockers, and diuretics as first-line agents 2
Elderly Patients (≥85 years)
Continue lifelong BP-lowering treatment if well tolerated 1, 3. Consider more lenient targets (<140/90 mmHg) in those with symptomatic orthostatic hypotension or moderate-to-severe frailty 3.
Elevated BP with High Cardiovascular Risk (130-139/80-89 mmHg)
After 3 months of lifestyle intervention, initiate pharmacological treatment if BP remains ≥130/80 mmHg and 10-year cardiovascular risk is sufficiently high 1, 3.
Critical Pitfalls to Avoid
Never combine two RAS blockers (ACE inhibitor + ARB) as this increases adverse effects without additional benefit 1, 2, 3.
Do not delay confirmation of hypertension diagnosis: Use multiple measurements with validated devices, patient seated, arm at heart level, at least two readings per visit 2, 3. Consider ambulatory BP monitoring for unusual variability, suspected white coat hypertension, or resistant hypertension 1, 3.
Do not prescribe monotherapy as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg), as combination therapy achieves superior BP control 1, 2.
Do not neglect lifestyle modifications even when initiating pharmacological therapy, as they enhance medication efficacy and may reduce the number/dose of drugs required 1, 6, 8.
Measure standing BP in elderly and diabetic patients to exclude orthostatic hypotension 1.
Medication Timing and Adherence
Patients should take medications at the most convenient time of day to establish a habitual pattern and improve adherence 1. High-fat meals decrease absorption of some agents (e.g., aliskiren), so establish a routine pattern regarding meals 5.
Single-pill fixed-dose combinations dramatically improve adherence and should be prescribed whenever possible 1, 2, 3.