What are the initial recommendations for managing hypertension?

Initial Management of Hypertension

For confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications and pharmacological therapy simultaneously, starting with combination therapy using a renin-angiotensin system (RAS) blocker plus either a calcium channel blocker or thiazide diuretic, preferably as a fixed-dose single-pill combination. 1

Blood Pressure Measurement and Diagnosis

• Measure BP using a validated device with the patient seated, arm at heart level, taking at least two measurements at each of several visits to confirm the diagnosis 2, 1
• Consider ambulatory or home BP monitoring when office readings show unusual variability, suspected white coat hypertension, or resistant hypertension 2
• Home BP readings are typically 10/5 mmHg lower than office readings and are the most practical method for medication titration 2, 3

Cardiovascular Risk Assessment

• Estimate 10-year cardiovascular disease risk using validated tools (SCORE in Europe, or equivalent risk calculators) to guide treatment intensity 2
• Screen for target organ damage including left ventricular hypertrophy, chronic kidney disease, and proteinuria, as these findings reclassify patients to higher risk categories 2, 1
• Document presence of diabetes, established cardiovascular disease, or renal impairment, as these conditions mandate more aggressive treatment targets 1, 3

Treatment Thresholds and Timing

For BP ≥140/90 mmHg: Start both lifestyle interventions and pharmacological therapy immediately, regardless of cardiovascular risk 2, 1

For BP 120-139/70-89 mmHg (elevated BP):

• Initiate pharmacological treatment if 10-year CVD risk ≥10%, or if high-risk conditions present (diabetes, CKD, established CVD) 1
• For low-to-moderate risk patients, implement intensive lifestyle modifications for 3 months before considering drug therapy 2, 4

For BP ≥180/110 mmHg: This requires urgent treatment initiation 3

Lifestyle Modifications (Essential for All Patients)

Lifestyle interventions are the cornerstone of hypertension management and should be implemented in all patients, even those requiring medications 2, 5

Dietary modifications:

• Follow the DASH (Dietary Approaches to Stop Hypertension) diet or Mediterranean diet, emphasizing fruits, vegetables, whole grains, and low-fat dairy products 2, 4
• Reduce sodium intake to <2 grams per day (approximately 5 grams of salt) 2, 5
• Increase dietary potassium intake unless contraindicated by kidney disease 2, 5

Weight management:

• Achieve and maintain ideal body weight (BMI <25 kg/m²) through reduced calorie and fat intake 2, 5
• Weight loss is particularly effective, with each 1 kg reduction lowering BP by approximately 1 mmHg 4, 6

Physical activity:

• Engage in regular aerobic exercise (predominantly dynamic activities like brisk walking rather than isometric weight training) for at least 150 minutes per week 2, 5

Alcohol moderation:

• Limit consumption to ≤2 standard drinks per day (maximum 14/week for men, 9/week for women) 2, 7

Smoking cessation:

• Recommend complete cessation for cardiovascular disease prevention 2, 4

Pharmacological Management

Initial drug therapy for most patients with BP ≥140/90 mmHg:

• Start with combination therapy using two drugs from different classes, preferably as a fixed-dose single-pill combination to improve adherence 1, 5
• Preferred initial combinations: RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker (amlodipine), OR RAS blocker + thiazide/thiazide-like diuretic 1, 5

First-line drug classes:

• Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide due to longer duration of action) 2, 5
• ACE inhibitors (e.g., lisinopril 10 mg once daily initially) or ARBs 8, 5
• Calcium channel blockers (long-acting amlodipine preferred) 2, 5

Specific dosing guidance:

• Lisinopril: Start 10 mg once daily, adjust to usual range of 20-40 mg daily based on response 8
• If patient is on diuretics, start lisinopril at 5 mg once daily 8
• Hydrochlorothiazide: Initial dose 12.5-25 mg once daily, maximum 50 mg daily 9

Blood Pressure Targets

Standard target for most patients:

• Systolic BP: 120-129 mmHg 1
• Diastolic BP: 70-79 mmHg 1
• Minimum acceptable control: <140/85 mmHg 3

Lower targets (<130/80 mmHg) for:

• Patients with diabetes 3, 5
• Chronic kidney disease 3, 5
• Established cardiovascular disease 3, 5

Modified approach for special populations:

• Elderly patients ≥80 years: Maintain treatment if well tolerated, but may accept systolic BP <140 mmHg rather than intensive targets 2, 3
• Patients with orthostatic hypotension or frailty: More relaxed targets, though asymptomatic orthostatic hypotension should not preclude treatment 2, 3

Monitoring and Follow-up

• Schedule monthly visits until BP target is achieved, then every 1-3 months during titration phase 2, 1
• Aim to achieve BP control within 3 months of treatment initiation 1
• Utilize home BP self-monitoring and telemonitoring to facilitate drug titration and maintain control 2
• Replace 30-day prescriptions with 90-day refills once stable to improve adherence 2
• Reassess cardiovascular risk annually 1, 3

Implementation Strategies to Improve Control

• Use fixed-dose combination pills rather than separate medications to enhance adherence 2, 1
• Implement team-based care with multidisciplinary involvement (pharmacists, nurses, health coaches) 2
• Screen for social determinants of health and address barriers to care 2
• Enhance connectivity between patient, provider, and electronic health records for better communication 2
• Consider telehealth strategies to augment office-based management 2

Common Pitfalls to Avoid

• Do not delay pharmacological therapy in patients with confirmed hypertension ≥140/90 mmHg waiting for lifestyle modifications alone to work 1
• Do not use monotherapy as initial treatment in most patients; combination therapy is more effective and achieves targets faster 1
• Do not withhold treatment due to asymptomatic orthostatic hypotension, as this is not associated with increased adverse events 2
• Do not accept suboptimal control (<140/90 mmHg) when lower targets are achievable and appropriate for the patient 1, 5
• If hypotension occurs after initial dosing, this does not preclude careful subsequent titration after managing the hypotension 8