What are the initial steps in managing hypertension?

Management of Hypertension

Diagnosis and Confirmation

Confirm hypertension using validated automated upper arm cuff devices with proper cuff sizing, measuring both arms at the first visit and using the higher reading for subsequent measurements. 1, 2

• Diagnostic thresholds differ between US and European guidelines:
  • American Heart Association defines hypertension as office BP ≥130/85 mmHg 1
  • European Society of Cardiology uses ≥140/90 mmHg 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, cardiovascular risk factors, and secondary causes of hypertension 1, 2

Lifestyle Modifications (First-Line for All Patients)

Implement comprehensive lifestyle changes immediately for all patients with elevated blood pressure, as these interventions reduce BP by 5-20 mmHg and may eliminate the need for medications. 1, 3

Dietary Interventions

• Follow DASH eating pattern with sodium restriction to <2,300 mg/day (can reduce BP by 10-20 mmHg in resistant hypertension) 1, 4
• Consume 8-10 servings of fruits and vegetables daily for potassium intake 1
• Include 2-3 servings of low-fat dairy products daily 1
• Consider Mediterranean diet pattern as an alternative 2

Weight Management

• Achieve and maintain BMI 20-25 kg/m² through caloric restriction for overweight/obese patients 1, 2
• Weight loss is particularly effective in resistant hypertension 5

Physical Activity

• Complete at least 150 minutes of moderate-intensity aerobic exercise weekly 1, 2
• Add resistance training 2-3 times weekly 2
• Exercise alone can significantly reduce BP in resistant hypertension 5

Alcohol and Smoking

• Limit alcohol to ≤2 drinks/day for men and ≤1 drink/day for women (or preferably <100g/week total) 1, 2
• Complete smoking cessation with appropriate support 1, 2

Pharmacological Therapy Initiation

The decision to start medications depends on BP level and cardiovascular risk, with significant differences between US and European approaches:

When to Start Medications

For BP ≥150/90 mmHg: Start drug therapy immediately alongside lifestyle modifications regardless of risk. 1

For BP 140-149/90-99 mmHg: European guidelines recommend immediate drug therapy for all patients, while US guidelines reserve this for high-risk patients only. 2

For BP 130-139/80-89 mmHg: Start medications only in high-risk patients (established CVD, CKD, diabetes, target organ damage, or age 50-80 years). 1, 2

Initial Drug Selection

Start with combination therapy (two drugs) as a single-pill combination for most patients with BP ≥140/90 mmHg, as this provides more effective BP control. 2

For Non-Black Patients:

• Preferred initial regimen: ACE inhibitor (or ARB) + dihydropyridine calcium channel blocker 2
• Alternative: ACE inhibitor (or ARB) + thiazide/thiazide-like diuretic 2
• First-line drug classes include ACE inhibitors, ARBs, thiazide-like diuretics, and dihydropyridine calcium channel blockers 1

For Black Patients:

• Start with ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide/thiazide-like diuretic 1, 2
• Black patients respond better to calcium channel blockers and diuretics than to RAS blockers as monotherapy 2

Special Populations Requiring Monotherapy:

• Patients >80 years or frail: Consider starting with lower-dose monotherapy 1, 2
• Low-risk grade 1 hypertension: May start with monotherapy 2

Disease-Specific First-Line Choices

• Diabetes, CKD, or albuminuria (UACR ≥30 mg/g): Use ACE inhibitor or ARB as first-line 1
• Established coronary artery disease: Use ACE inhibitor or ARB 1

Specific Dosing Example (Lisinopril)

• Initial dose: 10 mg once daily for hypertension 6
• Usual dosage range: 20-40 mg daily 6
• If taking diuretics: Start with 5 mg once daily 6
• May add low-dose diuretic (hydrochlorothiazide 12.5 mg) if BP not controlled 6

Treatment Escalation Algorithm

If BP remains uncontrolled after 2-4 weeks on dual therapy, escalate to three-drug combination: RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic. 2

Fourth-Line Therapy:

• Add spironolactone 25 mg once daily 2
• If spironolactone not tolerated: Consider eplerenone, amiloride, higher-dose thiazide, or loop diuretic 2

Fifth-Line Therapy:

• Add bisoprolol or doxazosin 2

Critical Pitfall:

• Never combine two RAS blockers (ACE inhibitor + ARB) as this is potentially harmful 2

Blood Pressure Targets

Target BP <130/80 mmHg for most adults under 65 years. 2

• Adults 65-85 years: Target systolic BP 120-129 mmHg if well tolerated 2
• Adults >85 years: Individualize based on frailty; systolic BP 130-139 mmHg if well tolerated 2
• High-risk patients: Ideally <130/80 mmHg 4
• Home BP monitoring target: <135/85 mmHg 4

Monitoring and Follow-Up

Achieve target BP within 3 months through monthly visits and medication adjustments. 1, 2, 4

Laboratory Monitoring:

• Check serum creatinine and potassium 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1, 2

Home BP Monitoring:

• Implement home BP monitoring to guide medication adjustments and improve adherence 1, 2, 4
• Home monitoring improves diagnosis acceptance, patient empowerment, and treatment adherence 4

Reassessment Schedule:

• Reassess within 2-4 weeks after each treatment adjustment 4
• Continue monthly visits until target achieved 1, 2

Adherence and Treatment Optimization

Use single-pill combinations to reduce therapy complexity and improve adherence, as non-adherence affects 10-80% of hypertensive patients. 4

• Employ motivational interviewing to increase adherence to treatment and lifestyle modifications 4
• Before assuming treatment failure, confirm medication adherence and rule out secondary causes 4
• Restrict sodium to <2.3g/day in resistant hypertension for additional 10-20 mmHg reduction 4

When to Refer

Refer to hypertension specialist for multiple drug intolerance or suspected secondary hypertension. 4

• Avoid delaying treatment intensification in stage 2 hypertension (≥160/100 mmHg) as this increases cardiovascular risk 4

Long-Term Management

• Maintain BP-lowering treatment lifelong, even beyond age 85 if well tolerated 2
• Every 10 mmHg reduction in systolic BP decreases CVD events by 20-30% 3
• Lifestyle modifications should continue even after starting medications, as they minimize the number and dose of medications required 3