What is the approach to medical management of hypertension?

Medical Management of Hypertension

For most patients with confirmed hypertension (BP ≥140/90 mmHg), initiate combination therapy with two first-line agents—preferably a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic—using a single-pill combination to improve adherence and achieve BP control within 3 months. 1

Blood Pressure Targets

• Target BP <130/80 mmHg for most adults under 65 years with hypertension 1
• Target systolic BP <130 mmHg for adults ≥65 years 1
• For patients with diabetes and cardiovascular disease or 10-year ASCVD risk ≥15%, target <130/80 mmHg if safely achievable 1
• Exception: Slower titration and potentially less aggressive targets (consider <140/90 mmHg) for those aged ≥85 years, moderate-to-severe frailty, symptomatic orthostatic hypotension, or limited life expectancy 1

Lifestyle Modifications (Foundation for All Patients)

Lifestyle interventions are recommended for anyone with BP >120/80 mmHg and should be initiated alongside pharmacologic therapy when hypertension is diagnosed 1:

• Weight loss if overweight or obese 1, 2
• Dietary sodium restriction to <2,300 mg/day 1, 2
• Increased potassium intake (8-10 servings of fruits and vegetables daily) 1
• DASH-style eating pattern 1, 2
• Regular physical activity: moderate-intensity aerobic exercise for at least 30 minutes on at least 3 days per week, or resistance exercise 2-3 days per week 3
• Alcohol moderation or elimination 1, 2

These interventions can reduce systolic BP by approximately 5 mmHg, which translates to a 9% reduction in coronary heart disease mortality and 14% reduction in stroke mortality 3.

Pharmacologic Treatment Algorithm

Step 1: Initial Therapy Based on BP Severity

BP 140-159/90-99 mmHg:

• May initiate with combination therapy (preferred) or single agent 1
• Exceptions for monotherapy: elevated BP (120-139/70-89 mmHg) with compelling indication, age ≥85 years, symptomatic orthostatic hypotension, or moderate-to-severe frailty 1

BP ≥160/100 mmHg:

• Mandatory combination therapy with two drugs or single-pill combination 1
• More rapid BP control needed due to higher cardiovascular risk 1

Step 2: First-Line Drug Classes

The following four drug classes have the strongest evidence for reducing BP and cardiovascular events 1:

1. ACE inhibitors (e.g., lisinopril, enalapril) 1, 2
2. Angiotensin receptor blockers (ARBs) (e.g., candesartan) 1, 2
3. Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2
4. Thiazide/thiazide-like diuretics (e.g., chlorthalidone, indapamide, hydrochlorothiazide) 1, 2

Preferred initial combinations:

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB 1
• RAS blocker (ACE inhibitor or ARB) + thiazide/thiazide-like diuretic 1

Critical: Use fixed-dose single-pill combinations whenever possible to improve adherence 1.

Step 3: Beta-Blockers (Compelling Indications Only)

Beta-blockers are not first-line for uncomplicated hypertension but should be added when specific indications exist 1:

• Post-myocardial infarction 1
• Angina pectoris 1
• Heart failure with reduced ejection fraction 1
• Heart rate control (e.g., atrial fibrillation) 1

Avoid beta-blockers in metabolic syndrome due to adverse effects on insulin sensitivity, lipid profile, and increased risk of new-onset diabetes 1.

Step 4: Escalation for Uncontrolled BP

If BP not controlled on two-drug combination:

• Escalate to three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1
• Preferably as single-pill combination 1

If BP not controlled on three-drug combination (resistant hypertension):

• Add spironolactone (mineralocorticoid receptor antagonist) 1
• If spironolactone not effective or tolerated, consider: eplerenone, beta-blocker (if not already prescribed), alpha-blocker, centrally acting agent, or hydralazine 1

Never combine two RAS blockers (ACE inhibitor + ARB)—this increases risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 1.

Timing and Titration

• Achieve BP target within 3 months to maintain patient confidence and reduce cardiovascular risk 1
• Medication timing: Take at the most convenient time of day to improve adherence; no evidence supports specific diurnal timing for cardiovascular outcomes 1
• Encourage same time daily in consistent setting 1

Monitoring and Follow-Up

• Confirm diagnosis with out-of-office BP measurement (home or ambulatory monitoring) before initiating treatment 1
• Home BP monitoring is recommended for ongoing management to achieve better BP control 1
• Monitor for adverse effects, particularly:
  • Hyperkalemia with RAS blockers and spironolactone 1
  • Hypotension (especially in heart failure, elderly, volume-depleted patients) 4
  • Angioedema with ACE inhibitors (0.1% incidence, higher in Black patients) 4
  • Cough with ACE inhibitors (switch to ARB if problematic) 4

Special Populations

Diabetes:

• Target <130/80 mmHg 1
• RAS blockers (ACE inhibitors or ARBs) preferred due to renoprotective effects and lower incidence of new-onset diabetes 1

Coronary Artery Disease/Stable Angina:

• Beta-blockers are first choice for angina and secondary prevention post-MI (at least 6 months) 1
• Target <130/80 mmHg 1

Chronic Kidney Disease:

• Target <130/80 mmHg 1
• RAS blockers preferred for proteinuria reduction 1

Pregnancy/Pre-eclampsia:

• Target ≤135/85 mmHg 1
• Avoid ACE inhibitors and ARBs (teratogenic) 4
• Use labetalol or long-acting nifedipine for severe pre-eclampsia 1

Metabolic Syndrome:

• Prefer RAS blockers or calcium channel blockers (metabolically neutral) 1
• Low-dose thiazide acceptable as second/third agent 1
• Avoid beta-blockers unless compelling indication 1

Common Pitfalls to Avoid

• Clinical inertia: Failure to intensify therapy when BP remains uncontrolled—titrate within 3 months 1
• Monotherapy in severe hypertension: BP ≥160/100 mmHg requires combination therapy from the start 1
• Non-adherence: Use single-pill combinations and assess adherence with a no-blame approach 1
• Excessive BP lowering: Avoid rapid drops >70 mmHg in first hour, especially in intracerebral hemorrhage 1
• Ignoring lifestyle modifications: These enhance medication efficacy and should always be emphasized 1, 2