What is the approach to managing hypertension?

Management of Hypertension

Diagnosis and Confirmation

Blood pressure should be confirmed using out-of-office measurements—either home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg)—before initiating treatment. 1, 2

• Use validated automated upper arm cuff devices with appropriate cuff size, taking at least two measurements per visit over multiple visits 1, 2
• Measure BP in both arms at first visit and use the higher reading 2
• Check standing BP in elderly patients and those with diabetes to assess for orthostatic hypotension 2
• Out-of-office monitoring is essential to detect white coat hypertension and masked hypertension 3

Initial Evaluation

Complete the following workup before initiating therapy:

• Urinalysis for blood and protein 1
• Blood electrolytes, creatinine, glucose, and lipid profile 1
• 12-lead ECG 1
• Formal cardiovascular risk assessment to guide treatment intensity 1
• Screen for secondary causes in patients with resistant hypertension, including primary aldosteronism 3

Lifestyle Modifications (First-Line for All Patients)

Lifestyle modification is the cornerstone of hypertension management and should be implemented in all patients, whether or not pharmacological therapy is initiated. 3, 1

Dietary Interventions

• DASH diet: Emphasize fruits (8-10 servings/day), vegetables, whole grains, low-fat dairy products (2-3 servings/day), and reduced saturated fat—reduces systolic BP by 5-8 mmHg 3, 1, 2
• Sodium restriction: Limit to <2,300 mg/day (approximately 5-6 g salt), which reduces systolic BP by 2-8 mmHg 3, 1, 2
• Potassium supplementation: Increase through fruits and vegetables 3, 2
• Eliminate table salt use 2

Weight Management

• Target BMI 20-25 kg/m² and waist circumference <102 cm (men) or <88 cm (women) 1, 2
• Each 1 kg weight loss reduces systolic BP by approximately 1 mmHg 1, 2

Alcohol Moderation

• Men: ≤2 standard drinks/day (maximum 14/week) 3, 2
• Women: ≤1 standard drink/day (maximum 7-9/week) 3, 2
• Include alcohol-free days each week 2
• One standard drink = 14 g pure alcohol (12 oz beer, 5 oz wine, or 1.5 oz spirits) 2

Physical Activity

• Minimum 150 minutes/week of moderate aerobic exercise (30 minutes on 5-7 days/week) 1, 2
• Add resistance training 2-3 times/week 1, 2
• Exercise reduces systolic BP by 4-9 mmHg 1, 2

The BP-lowering effects of individual lifestyle components are partially additive and enhance the efficacy of pharmacologic therapy. 4

Pharmacological Treatment Initiation

When to Start Medication

Initiate pharmacological therapy for BP ≥140/90 mmHg regardless of cardiovascular risk, or for BP ≥130/80 mmHg in patients with high cardiovascular risk (diabetes, chronic kidney disease, or established CVD). 1, 2

• For BP ≥160/100 mmHg: Prompt initiation of dual therapy in addition to lifestyle modifications 2
• For malignant hypertension or hypertensive emergency: Initiate treatment immediately without delay 2

First-Line Combination Therapy

Start with combination therapy using a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1, 2

Preferred initial combinations:

• ACE inhibitor or ARB + dihydropyridine calcium channel blocker 1, 2
• ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1, 2
• Calcium channel blocker + thiazide/thiazide-like diuretic 2

Use fixed-dose single-pill combinations to improve adherence. 1, 2

Medication Classes

First-line agents demonstrated to reduce cardiovascular events:

• ACE inhibitors (e.g., enalapril) 3, 4
• ARBs (e.g., candesartan) 3, 4
• Thiazide/thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide) 3, 4
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 3, 4

Critical Contraindication

Never combine two RAS blockers (ACE inhibitor + ARB) as this increases harm without additional benefit. 3, 2

Titration Strategy

If BP target is not achieved with dual therapy, progress to triple therapy with ACE inhibitor/ARB + calcium channel blocker + thiazide/thiazide-like diuretic. 1

• Titrate medications to maximum tolerated doses 3
• Monthly follow-up visits until BP target is achieved (goal: within 3 months) 1, 2
• Utilize home BP monitoring to guide medication adjustments 3, 1, 2

Blood Pressure Targets

Target BP varies by patient characteristics:

• Adults <65 years: 120-129/70-79 mmHg 2
• Adults ≥65 years: Systolic <130 mmHg 2
• Diabetes, CKD, or established CVD: ≤130/80 mmHg 3, 2

Note: Home and ambulatory BP readings run approximately 10/5 mmHg lower than office readings; adjust targets accordingly 2

Special Populations

Chronic Kidney Disease

• Use ACE inhibitor or ARB as first-line therapy, especially with albuminuria (UACR ≥30 mg/g) 3
• Target BP <130/80 mmHg (<140/80 in elderly patients) 3
• Use loop diuretics if eGFR <30 ml/min/1.73m² 3
• Monitor eGFR, microalbuminuria, and electrolytes 3

Diabetes

• Target BP <130/80 mmHg (<140/80 in elderly patients) 3
• Use RAS inhibitor as first-line therapy 3
• Add statin therapy for lipid management 3
• Monitor serum creatinine and potassium 2-4 weeks after initiating or changing doses of ACE inhibitors, ARBs, or aldosterone antagonists 3, 2

Coronary Artery Disease

• ACE inhibitors or ARBs are recommended as first-line therapy 3

Pregnancy

• ACE inhibitors, ARBs, and spironolactone are contraindicated in pregnancy due to fetal toxicity 3, 5
• Safe alternatives: methyldopa, labetalol, long-acting nifedipine 3
• Target BP 110-135/85 mmHg to balance maternal and fetal outcomes 3

Resistant Hypertension

Resistant hypertension is defined as BP ≥130/80 mmHg on ≥3 antihypertensive medications of different classes at maximum tolerated doses, or BP <130/80 mmHg requiring ≥4 drugs. 3

• Exclude pseudo-resistance: inaccurate BP measurement, white coat effect, suboptimal drug adherence 3
• Screen all patients for primary aldosteronism 3
• Consider 24-hour urine aldosterone measurement during salt loading if aldosterone-to-renin ratio is low but plasma renin is low 3

Monitoring and Follow-Up

• Monitor serum creatinine and potassium 2-4 weeks after initiating or changing doses of RAS inhibitors or aldosterone antagonists 2
• Once BP is controlled, consider 90-day medication refills rather than 30-day to improve adherence 1, 2
• Continue home BP monitoring for long-term management 3, 1

Implementation Strategies

Team-based care is the most effective approach for achieving BP control, with home BP monitoring and telemonitoring facilitating medication titration and maintenance of BP goals. 3, 1

• Enhance connectivity between patient, provider, and electronic health record 3
• Screen for social determinants of health and obstacles to care 3
• Use multidisciplinary teams to enhance lifestyle and medication adherence 3

Clinical Outcomes

Effective BP control reduces stroke incidence by 35-40%, myocardial infarction by 20-25%, and heart failure by 50%. 1

• An SBP reduction of 10 mmHg decreases risk of CVD events by approximately 20-30% 4
• For every 12 mmHg systolic BP reduction maintained over 10 years, one death is prevented for every 11 treated patients with additional cardiovascular risk factors 1, 2

Common Pitfalls to Avoid

• Do not delay treatment in young adults with hypertension and target organ damage—they have earlier onset of CVD events compared to those with normal BP 3
• Intensive BP control does not increase risk of orthostatic hypotension or injurious falls—asymptomatic orthostatic hypotension should not be a reason to withdraw or down-titrate treatment 3
• Do not use monotherapy as initial treatment for most patients with confirmed hypertension—combination therapy is more effective 1, 2
• Ensure consistent timing of medication relative to meals when using certain agents like aliskiren, as high-fat meals decrease absorption 5