What are the recommended treatments for hypertension?

Treatment of Hypertension

Start most adults with confirmed hypertension on combination therapy using 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 systolic blood pressure of 120-129 mmHg if tolerated. 1

Initial Assessment and Diagnosis

Confirm hypertension when office blood pressure readings are consistently ≥140/90 mmHg using validated automated upper arm cuff devices, with verification through home blood pressure monitoring (<135/85 mmHg) or 24-hour ambulatory monitoring (<130/80 mmHg). 2 Measure both arms at the first visit and use the arm with higher readings for subsequent measurements. 2

Lifestyle Modifications (Foundation for All Patients)

Implement these evidence-based interventions immediately for all patients with elevated blood pressure:

• Weight management: Reduce to ideal body weight through caloric restriction 1, 2
• Sodium restriction: Limit intake to <2,300 mg/day 1
• Dietary pattern: Consume 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 1
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• Sugar elimination: Remove sugar-sweetened beverages and restrict free sugar to maximum 10% of energy intake 1
• Tobacco cessation: Complete cessation with referral to smoking cessation programs 1
• Regular exercise: Engage in regular physical activity 2, 3

The combination of these lifestyle modifications produces additive blood pressure reductions and enhances pharmacologic therapy effectiveness. 3 A comprehensive lifestyle intervention (DASH diet, sodium restriction, weight loss, and exercise) can reduce 24-hour ambulatory systolic/diastolic blood pressure by 9.5/5.3 mmHg in hypertensive patients already on medication. 4

Pharmacological Treatment Algorithm

Step 1: Initial Dual Therapy

For non-Black patients:

• Start with ACE inhibitor (e.g., lisinopril 5) or ARB plus dihydropyridine calcium channel blocker (e.g., amlodipine 6) OR thiazide/thiazide-like diuretic 1, 2
• Preferably use single-pill combination to improve adherence 1

For Black patients:

• Start with dihydropyridine calcium channel blocker plus thiazide/thiazide-like diuretic OR combine either with a RAS blocker 1, 2
• This approach addresses the smaller blood pressure effects of RAS blockers as monotherapy in Black patients 5, 6

Step 2: Triple Therapy (If BP Remains Uncontrolled)

Add a third agent to create the combination of RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic. 1

Step 3: Resistant Hypertension

Consider spironolactone as the fourth-line agent when blood pressure remains uncontrolled on triple therapy. 2

Blood Pressure Targets

• Most adults: 120-129 mmHg systolic (if well tolerated) 1
• Standard target: <130/80 mmHg for most patients 2, 3
• Diabetes: <130/80 mmHg 1, 2
• Chronic kidney disease: 120-129 mmHg systolic (if tolerated) 1
• Elderly patients (≥65 years): <130 mmHg systolic 3
• Heart failure: <130/80 mmHg but maintain >120/70 mmHg 2

Achieve target blood pressure within 3 months of initiating therapy. 1, 2

Special Population Considerations

Patients with albuminuria/proteinuria:

• Use RAS blockers as first-line due to superior albuminuria reduction 1

High-risk patients (cardiovascular disease, chronic kidney disease, diabetes, organ damage, or age 50-80 years):

• Start medications immediately when BP ≥140/90 mmHg 2

Low-moderate risk patients:

• Implement lifestyle modifications for 3-6 months before starting medications if BP ≥140/90 mmHg persists 2

Coronary artery disease:

• Target <130/80 mmHg (<140/80 in elderly); use RAS blockers and beta-blockers with or without calcium channel blockers 2

Previous stroke:

• Target <130/80 mmHg (<140/80 in elderly); use RAS blockers, calcium channel blockers, and diuretics 2

Heart failure with preserved ejection fraction (HFpEF):

• Add SGLT2 inhibitors for symptomatic patients 1

Monitoring and Long-Term Management

• Monitor renal function and potassium at least annually when using ACE inhibitors, ARBs, or diuretics 1
• Administer medications at the most convenient time to establish routine and improve adherence 1
• Maintain treatment lifelong, even beyond age 85, if well tolerated 1
• Use objective methods to monitor medication adherence when possible 2
• Refer to a hypertension specialist if blood pressure remains uncontrolled despite appropriate therapy 2

Clinical Outcomes

A 10 mmHg reduction in systolic blood pressure decreases cardiovascular disease events by approximately 20-30%, with the largest benefit being stroke risk reduction. 3 Blood pressure reduction itself, rather than specific drug properties, is primarily responsible for cardiovascular morbidity and mortality benefits. 5, 6, 3