What is the recommended treatment for hypertension?

Recommended Treatment for Hypertension

For most adults with confirmed hypertension (≥140/90 mmHg), initiate combination pharmacological 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, while simultaneously implementing lifestyle modifications targeting a systolic BP of 120-129 mmHg if tolerated. 1, 2

Initial Pharmacological Treatment Algorithm

First-Line Combination Therapy

• Start with two-drug combination for most patients with hypertension (BP ≥140/90 mmHg): 1, 2

  • RAS blocker (ACE inhibitor like lisinopril 10 mg daily OR ARB) 3
  • PLUS dihydropyridine calcium channel blocker (e.g., amlodipine) 1
  • OR thiazide/thiazide-like diuretic (e.g., chlorthalidone, hydrochlorothiazide 12.5 mg) 1, 3

• Use single-pill combination formulations to improve adherence 1, 2

Special Population Considerations

• Black patients: Initiate with diuretic or calcium channel blocker, either in combination or with a RAS blocker 2
• Patients ≥85 years, symptomatic orthostatic hypotension, or moderate-to-severe frailty: Consider monotherapy initially 1
• Elevated BP (120-139/70-89 mmHg) with high CVD risk: Start pharmacological therapy 1, 2
• Elevated BP with low CVD risk (<10% 10-year risk): Lifestyle modifications alone 1, 2

Treatment Escalation Protocol

Step 2: Three-Drug Combination

• If BP remains uncontrolled on two drugs, escalate to: 1, 2
  • RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic
  • Preferably as single-pill combination 1, 2

Step 3: Resistant Hypertension (Four-Drug Regimen)

• Add spironolactone (low-dose) to the three-drug combination 1, 2
• If spironolactone not tolerated or ineffective, consider: 1
  • Eplerenone (alternative mineralocorticoid receptor antagonist) 1
  • Beta-blocker (if not already indicated) 1
  • Alpha-blocker (doxazosin) 1
  • Centrally acting agent 1
  • Hydralazine 1

Critical Pitfall to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB together) 1

Blood Pressure Targets

• Standard target: Systolic BP 120-129 mmHg for most adults if well tolerated 1, 2
• Diabetes: <130/80 mmHg 2
• Chronic kidney disease: 120-129 mmHg systolic if tolerated 2
• Achieve target within 3 months of treatment initiation 1, 2

Concurrent Lifestyle Modifications (Mandatory, Not Optional)

These must be initiated simultaneously with pharmacological therapy, not sequentially: 1, 2

Weight Management

• Reduce to ideal body weight through caloric restriction 2
• Weight loss produces additive BP-lowering effects with medications 4

Dietary Interventions

• Sodium restriction to <2,300 mg/day 2, 4
• 8-10 servings of fruits/vegetables daily 2
• 2-3 servings of low-fat dairy products daily 2
• Eliminate sugar-sweetened beverages; limit free sugar to maximum 10% of energy intake 2
• Emphasize fresh foods over processed foods 5

Alcohol and Tobacco

• Limit alcohol: ≤2 drinks/day for men, ≤1 drink/day for women 2, 4
• Complete tobacco cessation with referral to cessation programs 2

Physical Activity

• Regular exercise (specific frequency/intensity not detailed in guidelines but consistently recommended) 2, 4, 6

Special Clinical Scenarios

Heart Failure with Preserved Ejection Fraction (HFpEF)

• Add SGLT2 inhibitors for symptomatic patients 2

Albuminuria or Proteinuria

• RAS blockers are first-line due to superior albuminuria reduction 2

Diabetes with Target Organ Damage

• Preferentially use RAS inhibitors (ARB or ACE inhibitor) and calcium channel blockers 1

Inflammatory Rheumatic Diseases

• Preferentially use RAS inhibitors and calcium channel blockers (evidence of overactive RAAS) 1

Psychiatric Disorders/Depression

• Preferentially use RAS inhibitors and diuretics (fewer drug interactions with antidepressants) 1
• Use calcium channel blockers and alpha-1 blockers cautiously in patients with orthostatic hypotension 1

Monitoring Requirements

• Follow-up every 1-3 months until BP controlled 1
• Monitor renal function and potassium at least annually when using ACE inhibitor, ARB, or diuretic 2
• Confirm diagnosis with out-of-office BP measurement (home or ambulatory monitoring) before initiating treatment 1
• Maintain treatment lifelong, even beyond age 85, if well tolerated 2

Key Clinical Pearls

• The BP-lowering effects of lifestyle modifications are partially additive and enhance medication efficacy 4
• A 10 mmHg systolic BP reduction decreases CVD events by 20-30% 4
• Medication timing should be at the most convenient time to establish routine and improve adherence 2
• If lifestyle changes effectively lower BP, pharmacological treatments may be down-titrated or stopped 1
• Only 44% of US adults with hypertension have BP controlled to <140/90 mmHg, highlighting the treatment gap 4