What is the complete treatment protocol for a patient?

Complete Treatment Protocol for Hypertension

Initial Assessment and Diagnosis Confirmation

For any patient presenting with elevated blood pressure, confirm the diagnosis using home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before initiating treatment. 1

• Measure blood pressure using a validated automated upper arm cuff device with appropriate cuff size 1
• At first visit, measure BP in both arms simultaneously; use the arm with consistently higher readings 1
• Obtain baseline laboratory studies: CBC, platelets, chemistry profile, and thyroid-stimulating hormone (TSH) 1
• Assess for target organ damage and cardiovascular risk factors (CVD, CKD, diabetes, age 50-80 years) 1

Treatment Initiation Strategy

For High-Risk Patients (CVD, CKD, diabetes, organ damage, or aged 50-80 years):

Start drug treatment immediately alongside lifestyle interventions. 1

For Low-Moderate Risk Patients:

Start lifestyle interventions first, then add drug treatment if BP remains elevated after 3-6 months. 1

Pharmacologic Treatment Algorithm

First-Line Therapy

For Non-Black Patients:

• Start with low-dose ACE inhibitor or ARB 1
• If already on amlodipine monotherapy, add an ACE inhibitor or ARB as the second agent 2

For Black Patients:

• Start with low-dose ARB plus dihydropyridine calcium channel blocker (DHP-CCB), or DHP-CCB plus thiazide/thiazide-like diuretic 1

Second-Line Therapy (If BP Remains Uncontrolled)

For Non-Black Patients:

• Add DHP-CCB (amlodipine 5-10mg daily) to ACE inhibitor/ARB 2
• Increase to full doses before adding third agent 1

For Black Patients:

• Increase to full doses of initial combination 1
• Add diuretic or ACE inhibitor/ARB as third agent 1

Third-Line Therapy (Triple Therapy)

Add thiazide or thiazide-like diuretic to the ACE inhibitor/ARB plus calcium channel blocker combination. 2

• Preferred agents: chlorthalidone 12.5-25mg daily (preferred due to longer duration) or hydrochlorothiazide 25-50mg daily 2
• This creates the evidence-based triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 2
• Check serum potassium and creatinine 2-4 weeks after initiating diuretic therapy 2

Fourth-Line Therapy (Resistant Hypertension)

If BP remains uncontrolled despite optimized triple therapy, add spironolactone 25-50mg daily as the preferred fourth-line agent. 2

• Monitor potassium closely when adding spironolactone to an ACE inhibitor due to significant hyperkalemia risk 2
• Alternative fourth-line agents if spironolactone is not tolerated or contraindicated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Specific Dosing Considerations

Lisinopril Dosing (Example ACE Inhibitor):

• Initial dose: 5mg within 24 hours of starting treatment 3
• Maintenance: 10mg daily 3
• For patients with systolic BP <120 mmHg at baseline: start with 2.5mg 3
• If hypotension occurs, reduce dose; if severe hypotension occurs, discontinue 3

Blood Pressure Targets

Target BP <140/90 mmHg minimum for most patients; ideally <130/80 mmHg for higher-risk patients. 1, 2

• Individualize targets for elderly patients based on frailty 1
• Aim to reduce BP by at least 20/10 mmHg from baseline 1

Monitoring Schedule

Short-Term Monitoring:

• Reassess BP within 2-4 weeks after any medication adjustment 2
• Achieve target BP within 3 months of initiating or modifying therapy 1, 2
• Check serum potassium and creatinine 2-4 weeks after starting diuretics or spironolactone 2

Long-Term Monitoring:

• Interim history and physical: every 2-4 months for 1-2 years, then every 3-6 months for next 3-5 years 1
• Laboratory studies (CBC, platelets, chemistry profile): every 2-4 months for 1-2 years, then every 3-6 months 1
• Annual influenza vaccine 1

Critical Pitfalls to Avoid

Do not combine ACE inhibitors with ARBs—this increases adverse events without additional benefit. 2

Do not add a beta-blocker as third-line therapy unless there are compelling indications (angina, post-MI, heart failure with reduced ejection fraction, or need for heart rate control). 2

Do not add a fourth drug class before maximizing doses of the current two-drug or three-drug regimen. 2

Always verify medication adherence and rule out secondary hypertension before assuming treatment failure—non-adherence is the most common cause of apparent treatment resistance. 2

Lifestyle Modifications (Essential Adjunct to All Pharmacotherapy)

Implement sodium restriction to <2g/day, which can provide additive BP reduction of 10-20 mmHg. 2

• Maintain healthy weight (target BMI 20-25 kg/m²) 2
• Regular aerobic exercise 2
• Limit alcohol to <100g/week 2

Referral Criteria

Refer to a hypertension specialist if:

• BP remains uncontrolled (≥160/100 mmHg) despite four-drug therapy at optimal doses 2
• Multiple drug intolerances are present 2
• Concerning features suggesting secondary hypertension are identified 2

Special Monitoring for Specific Agents

ACE Inhibitors/ARBs:

• Monitor for cough (ACE inhibitors), hyperkalemia, and acute kidney injury 2

Thiazide Diuretics:

• Monitor for hypokalemia, hyperuricemia, and glucose intolerance 2

Calcium Channel Blockers:

• Monitor for peripheral edema (may be attenuated by adding ACE inhibitor/ARB) 2