How to evaluate and manage a newly diagnosed patient with hypertension?

Evaluation and Management of Newly Diagnosed Hypertension

For newly diagnosed hypertension, immediately confirm the diagnosis with out-of-office blood pressure monitoring (home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg), perform targeted initial workup to assess cardiovascular risk and target organ damage, initiate lifestyle modifications in all patients, and start combination pharmacotherapy with two first-line agents (ACE inhibitor or ARB plus calcium channel blocker or thiazide diuretic) for BP ≥140/90 mmHg or for BP 130-139/80-89 mmHg with established cardiovascular disease, diabetes, chronic kidney disease, or 10-year cardiovascular risk ≥10%. 1, 2

Diagnostic Confirmation

• Confirm the diagnosis using out-of-office monitoring before labeling someone as hypertensive, as office readings can overestimate true BP due to white coat effect 1, 2
• Home BP monitoring threshold: ≥135/85 mmHg 1, 2
• 24-hour ambulatory BP monitoring threshold: ≥130/80 mmHg 1, 2
• Measure BP in both arms using a validated automated upper arm cuff with appropriate cuff size 3
• Check standing BP in elderly patients and those with diabetes to assess for orthostatic hypotension 2

Essential Initial Workup

Perform these specific tests to assess cardiovascular risk and target organ damage: 4, 2

• Urine strip test for blood and protein 4
• Serum electrolytes and creatinine to assess kidney function 4, 2
• Blood glucose to screen for diabetes 4, 2
• Lipid profile (total cholesterol and HDL cholesterol ratio) 4, 2
• 12-lead electrocardiogram to detect left ventricular hypertrophy or ischemic changes 4, 2
• Formal cardiovascular risk assessment using the ACC/AHA Pooled Cohort Equations to calculate 10-year ASCVD risk 4, 1

Screen for secondary hypertension if: 4

• Age <30 years with hypertension
• Sudden onset or worsening of hypertension
• Resistant hypertension (uncontrolled on 3 drugs)
• Hypokalemia (suggests primary aldosteronism)
• Abdominal bruit (suggests renovascular disease)

Lifestyle Modifications (All Patients)

Implement these specific interventions immediately, as they can lower systolic BP by 5-8 mmHg and are required regardless of whether medications are started: 1, 2, 5

• Weight reduction: Target BMI 20-25 kg/m²; expect approximately 1 mmHg SBP reduction per kg lost 1, 2
• DASH diet or Mediterranean diet: Rich in fruits, vegetables, whole grains, low-fat dairy, with reduced saturated fat 1, 2, 5
• Sodium restriction: Reduce intake to <2,300 mg/day (<2 g/day); eliminate table salt and avoid processed foods 4, 1, 2
• Physical activity: At least 150 minutes per week of moderate-intensity aerobic exercise 1, 5
• Alcohol limitation: Maximum 14 drinks/week for men, 9 drinks/week for women (or <2 standard drinks/day) 4, 1
• Smoking cessation: Essential for overall cardiovascular risk reduction 4

Pharmacological Treatment Algorithm

The decision to start medications depends on BP level and cardiovascular risk: 4, 1, 2

For BP ≥140/90 mmHg:

• Start combination therapy immediately with two first-line agents as a single-pill combination 1, 3, 2
• Preferred initial combinations: 1, 3, 2
  • ACE inhibitor (e.g., lisinopril) or ARB (e.g., losartan) + calcium channel blocker (e.g., amlodipine), OR
  • ACE inhibitor or ARB + thiazide diuretic (chlorthalidone preferred over hydrochlorothiazide) 2, 5

For BP 130-139/80-89 mmHg (Elevated/Stage 1):

• Start medications if: 10-year ASCVD risk ≥10%, established cardiovascular disease, diabetes, or chronic kidney disease 4, 1
• Lifestyle modifications only if: 10-year ASCVD risk <10% and no cardiovascular disease, diabetes, or chronic kidney disease 4, 1

For BP ≥160/100 mmHg (Stage 2):

• Never use monotherapy—these patients require dual therapy from the start 4, 3
• Consider starting with two medications at full doses rather than low doses 4

Critical pitfall to avoid: Never combine two RAS blockers (ACE inhibitor + ARB together), as this is potentially harmful 3

Blood Pressure Targets

Target BP for most adults <65 years: <130/80 mmHg 1, 3, 2

Target BP for adults ≥65 years: SBP <130 mmHg 3

Specific populations: 1

• Patients with diabetes: <130/80 mmHg
• Patients with chronic kidney disease: <130/80 mmHg
• Patients with established cardiovascular disease: <130/80 mmHg

Achieve target within 3 months of treatment initiation 1, 3

Medication Titration Protocol

If BP target not reached on dual therapy: 1, 3

1. Increase to triple therapy: ACE inhibitor or ARB + calcium channel blocker + thiazide diuretic 1, 3
2. Monitor electrolytes and renal function 2-4 weeks after initiating or intensifying ACE inhibitors, ARBs, or diuretics 1, 3

If BP remains ≥140/90 mmHg on maximally tolerated triple therapy (resistant hypertension): 3, 2

• Add spironolactone 25-50 mg daily as the fourth agent 3, 2
• Monitor serum potassium and creatinine 2-4 weeks after initiation, especially if patient is on RAS blocker 3
• If spironolactone not effective or not tolerated, consider eplerenone, beta-blockers, alpha-blockers, or central-acting agents 1

Follow-Up Strategy

• Re-evaluate BP every 2-4 weeks after initiating or intensifying treatment until target is reached 1
• Implement home BP monitoring to evaluate treatment effectiveness and improve adherence 1, 2
• Use team-based care: Delegate routine BP monitoring and medication adherence counseling to nurses, pharmacists, or community health workers 3, 2
• Utilize electronic health records to track and identify patients with uncontrolled hypertension 3, 2

Clinical Benefits of Treatment

For every 10 mmHg SBP reduction, expect: 2, 5

• 20-30% reduction in cardiovascular disease events
• 35-40% reduction in stroke incidence
• 20-25% reduction in myocardial infarction
• 50% reduction in heart failure

Common pitfall: Clinical inertia—failure to titrate or combine medications despite knowing the patient is not at goal BP—must be overcome through systematic protocols and decision support systems 4