What are the recommended treatments for managing hypertension?

Hypertension Management

For most adults with confirmed hypertension (BP ≥140/90 mmHg), immediately initiate combination pharmacological therapy with two first-line agents—preferably a RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic as a single-pill combination—while simultaneously implementing comprehensive lifestyle modifications. 1, 2

Diagnosis and Confirmation

• Measure blood pressure using a validated device with the patient seated, arm at heart level, taking at least two readings per visit across multiple visits to confirm the diagnosis 1, 3
• Check standing blood pressure in elderly and diabetic patients to exclude orthostatic hypotension 1
• Consider ambulatory blood pressure monitoring when clinic readings show unusual variability, suspected white coat hypertension, or apparent treatment resistance 1, 3
• Calculate 10-year cardiovascular disease risk to guide treatment intensity, particularly for patients with borderline hypertension (systolic 130-139 mmHg or diastolic 80-89 mmHg) 1, 2, 3

Lifestyle Modifications (Foundation for All Patients)

Weight and Body Composition:

• Target BMI 20-25 kg/m² and waist circumference <94 cm in men, <80 cm in women 1, 2
• Weight loss reduces blood pressure and enhances medication efficacy 4, 5, 6

Physical Activity:

• Perform at least 150 minutes per week of moderate-intensity aerobic exercise (or 75 minutes of vigorous activity) 1, 2, 3
• Add low- to moderate-intensity resistance training 2-3 times per week 1, 2, 3

Dietary Modifications:

• Adopt Mediterranean or DASH dietary patterns emphasizing fruits, vegetables, fish, nuts, and unsaturated fatty acids 1, 3
• Restrict sodium intake by avoiding table salt and eliminating excessively salty processed foods 1, 3, 4
• Limit free sugar consumption to maximum 10% of energy intake and discourage sugar-sweetened beverages 1, 3

Alcohol and Tobacco:

• Limit alcohol to <100 g/week of pure alcohol (approximately 14 units/week for men, 9 units/week for women), with complete avoidance preferred for optimal health outcomes 1, 3
• Stop all tobacco use immediately and refer to smoking cessation programs 1, 3

Pharmacological Treatment Algorithm

Initial Therapy (BP ≥140/90 mmHg):

• Start with two-drug combination therapy immediately using a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1, 2, 3, 4
• Prescribe as a single-pill fixed-dose combination to improve adherence 1, 2, 3

Exceptions to Combination Therapy:

• Patients aged ≥85 years 1
• Symptomatic orthostatic hypotension 1
• Moderate-to-severe frailty 1
• Elevated BP (systolic 120-139 mmHg or diastolic 70-89 mmHg) with concomitant indication for treatment 1

Escalation to Triple Therapy:

• If BP remains uncontrolled after 4 weeks on two-drug combination, escalate to RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 1, 2, 3

Resistant Hypertension (Fourth-Line):

• Add spironolactone when BP remains uncontrolled on triple therapy 3

Beta-Blockers:

• Reserve 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

Blood Pressure Targets

Standard Adult Targets (<65 years):

• Target systolic BP 120-129 mmHg and diastolic BP <80 mmHg if well tolerated 1, 2, 3
• This target reduces cardiovascular risk most effectively 1, 2

Older Adults (≥65 years):

• Target systolic BP 130-139 mmHg 2, 3

High-Risk Populations (diabetes, CKD, established CVD):

• Target BP <130/80 mmHg 2, 3, 4

Poorly Tolerated Treatment:

• Apply the "as low as reasonably achievable" (ALARA) principle when target of 120-129 mmHg cannot be tolerated 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, 3
• Note: The stroke reduction benefit of losartan in patients with left ventricular hypertrophy does not apply to Black patients 7

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
• Target BP <130/80 mmHg 2, 3
• Losartan specifically reduces progression of diabetic nephropathy in type 2 diabetes with elevated creatinine and proteinuria 7

Heart Failure:

• Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists for HFrEF 2, 3
• Consider SGLT2 inhibitors for HFpEF 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

Coronary Artery Disease:

• Target BP <130/80 mmHg 2
• Use RAS blockers and beta-blockers as first-line agents 2

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 rely on single blood pressure measurements for diagnosis; confirm with multiple readings across several visits 1, 3
• Do not overlook white coat hypertension—use ambulatory monitoring when office readings are persistently elevated despite apparent treatment 1, 3
• Do not neglect lifestyle modifications even when initiating pharmacotherapy; they are additive and may reduce medication requirements 1, 4, 8
• Do not use inadequate doses or inappropriate drug combinations; follow the evidence-based algorithm 2

Medication Timing and Adherence

• Take medications at the most convenient time of day to establish habitual patterns and improve adherence 1
• Single-pill fixed-dose combinations significantly improve adherence compared to multiple separate pills 1, 2, 3
• Employ multidisciplinary team approaches involving pharmacists to enhance adherence 2

Long-Term Management

• Continue BP-lowering treatment lifelong if well tolerated, even beyond age 85 years 1, 3
• Monitor with both office and home blood pressure readings 2, 3
• Reassess cardiovascular risk annually 2, 3
• Every 10 mmHg reduction in systolic BP decreases cardiovascular events by approximately 20-30% 4