What is the treatment for hypertension?

Treatment of Hypertension

For most adults with hypertension, initiate combination therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination, targeting a systolic blood pressure of 120-129 mmHg if tolerated. 1, 2

Blood Pressure Targets

• Standard target: 120-129 mmHg systolic for most adults if well tolerated 1, 2
• For patients with diabetes: <130/80 mmHg 1, 2
• For patients with chronic kidney disease: 120-129 mmHg systolic if tolerated 2
• Achieve target blood pressure within 3 months of initiating therapy 2

Lifestyle Modifications (Essential First-Line Therapy)

All patients require behavioral interventions alongside pharmacotherapy:

• Weight reduction to ideal body weight through caloric restriction 2
• Sodium restriction to <2,300 mg/day (or 65-100 mmol/day for hypertensive patients) 2, 3
• Dietary pattern: 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 2
• Aerobic exercise 30-60 minutes, 4-7 days per week 3
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women (maximum 14/week for men, 9/week for women) 2, 3
• Complete tobacco cessation with referral to smoking cessation programs 2
• Eliminate sugar-sweetened beverages and restrict free sugar to maximum 10% of energy intake 2

Pharmacological Treatment Algorithm

Step 1: Initial Two-Drug Combination

Start with RAS blocker (ACE inhibitor or ARB) PLUS dihydropyridine calcium channel blocker OR thiazide/thiazide-like diuretic, preferably as single-pill combination 1, 2, 4, 5

• ACE inhibitors (e.g., lisinopril, enalapril) are FDA-approved for hypertension and reduce cardiovascular morbidity and mortality 5
• ARBs (e.g., losartan, candesartan) are FDA-approved alternatives if ACE inhibitors are not tolerated 1, 4
• Thiazide/thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide) are FDA-approved and have demonstrated cardiovascular benefit 6, 7
• Dihydropyridine calcium channel blockers (e.g., amlodipine) complete the preferred combinations 1, 7

Special consideration for Black patients: Initial therapy should include a diuretic or calcium channel blocker, either in combination or with a RAS blocker 2

Step 2: Escalate to Three-Drug Combination

If blood pressure remains uncontrolled, add the third agent to create RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1, 2

Step 3: Resistant Hypertension Management

For patients with BP >140/90 mmHg despite three optimally dosed medications including a diuretic 1:

• First, reinforce lifestyle measures, especially sodium restriction 1
• Add low-dose spironolactone (mineralocorticoid receptor antagonist) to existing treatment 1
• If spironolactone is not tolerated: consider eplerenone, amiloride, higher-dose thiazide/thiazide-like diuretic, or loop diuretic 1
• Alternative additions: bisoprolol or doxazosin 1
• Refer to hypertension specialist if uncontrolled on three drugs including a diuretic, or if significant renal disease present 1

Special Population Considerations

Diabetes with Hypertension

• Target BP: <130/80 mmHg 1, 2
• ACE inhibitors or ARBs are first-line therapy, particularly beneficial for reducing cardiovascular events 1
• For patients with microalbuminuria or clinical nephropathy: ACE inhibitors (type 1 and type 2 diabetes) or ARBs (type 2 diabetes) are mandatory first-line therapy to prevent progression of nephropathy 1
• Beta-blockers and diuretics are also supported by evidence as alternative strategies 1
• Monitor renal function and serum potassium levels when using ACE inhibitors or ARBs 1

Chronic Kidney Disease with Proteinuria

• RAS blockers are first-line treatment due to superior albuminuria reduction 2, 3
• Target BP: 120-129 mmHg systolic if tolerated 2

Heart Failure with Reduced Ejection Fraction

• Combination therapy with diuretics, ACE inhibitors (or ARBs), beta-blockers, and aldosterone receptor antagonists 1
• Target BP: <130/80 mmHg, with consideration for lowering to <120/80 mmHg 1
• Avoid non-dihydropyridine CCBs (verapamil, diltiazem) due to negative inotropic effects 1
• Beta-blockers proven beneficial: carvedilol, metoprolol succinate, bisoprolol 1

Heart Failure with Preserved Ejection Fraction

• SGLT2 inhibitors are recommended for symptomatic patients 2

Elderly Patients

• Lower blood pressure gradually to avoid complications 1
• Maintain treatment lifelong, even beyond age 85, if well tolerated 2

Critical Monitoring Parameters

• Renal function and potassium levels at least annually when using ACE inhibitor, ARB, or diuretic 2
• Blood pressure measurement at every routine visit 1
• Orthostatic blood pressure measurements to assess for autonomic neuropathy, especially in diabetic patients 1
• Home blood pressure monitoring to enhance adherence and assess true BP control 7

Common Pitfalls to Avoid

• Do not use non-dihydropyridine CCBs (diltiazem, verapamil) in patients with heart failure due to negative inotropic effects 1
• Avoid alpha-blockers (doxazosin) as first-line therapy due to increased heart failure risk; reserve for resistant hypertension only 1
• Do not delay medication intensification—most patients require 2-3 drugs to achieve target BP 1
• In elderly patients with wide pulse pressures, lowering systolic BP may cause very low diastolic values (<60 mmHg); monitor carefully for myocardial ischemia 1
• Medication timing should be at the most convenient time to establish routine and improve adherence, not necessarily at bedtime 2