What are the recommended treatments for managing hypertension?

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 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
• 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 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

Coronary Artery Disease

• Target BP <130/80 mmHg 2
• Use RAS blockers and beta-blockers 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.

Left Ventricular Hypertrophy

Losartan reduces stroke risk in hypertensive patients with left ventricular hypertrophy, though this benefit does not apply to Black patients 4.

Diagnosis and Confirmation

• Use validated BP device with patient seated, arm at heart level 1, 3
• Take at least two measurements per visit across multiple visits to confirm diagnosis 1, 2
• Measure standing BP in elderly and diabetic patients to exclude orthostatic hypotension 1
• Consider ambulatory BP monitoring for unusual variability, suspected white coat hypertension, or resistant hypertension (≥3 drugs) 1, 3

Cardiovascular Risk Assessment

Calculate 10-year cardiovascular disease risk to guide treatment intensity for patients with elevated BP (130-139/80-89 mmHg) 1, 2, 3. For these patients with high cardiovascular risk (≥10%), initiate pharmacological treatment after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 1, 3.

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB) due to increased adverse effects without additional benefit 1, 2, 3
• Do not delay pharmacological treatment in confirmed hypertension (BP ≥140/90 mmHg) regardless of cardiovascular risk 1, 3
• Do not prescribe monotherapy as initial treatment for most patients with confirmed hypertension 1, 2
• Do not overlook lifestyle modifications when initiating pharmacological therapy 1, 3, 6
• Avoid inadequate dosing or inappropriate drug combinations 3

Medication Timing and Adherence

• Take medications at the most convenient time of day to establish habitual pattern and improve adherence 1
• Single-pill fixed-dose combinations are strongly preferred over separate pills 1, 2, 3
• Employ multidisciplinary team approaches involving pharmacists to enhance adherence 2
• Establish routine pattern regarding meals (high-fat meals decrease absorption of some agents like aliskiren) 5

Monitoring and Follow-Up

• Regular BP monitoring using both office and home readings 2, 3
• Annual cardiovascular risk reassessment 2, 3
• Reassess BP control after 2-4 weeks of therapy initiation or dose adjustment, as antihypertensive effect is substantially attained (85-90%) by 2 weeks 5
• Continue lifelong treatment if well tolerated, even beyond age 85 1, 2, 3