What is the approach to managing elevated blood pressure (hypertension)?

Approach to Elevated Blood Pressure

Initial Assessment and Diagnosis

For most patients with confirmed hypertension (BP ≥140/90 mmHg), initiate combination BP-lowering treatment immediately alongside lifestyle modifications, targeting a systolic BP of 120-129 mmHg if well tolerated. 1

Confirm the Diagnosis

• Verify elevated office BP readings with out-of-office measurements using home BP monitoring (HBPM) or 24-hour ambulatory BP monitoring (ABPM) before starting treatment to exclude white-coat hypertension 2
• Define elevated BP as systolic 120-139 mmHg or diastolic 70-89 mmHg 1
• Define hypertension as BP ≥140/90 mmHg 1

Risk Stratification

• Calculate 10-year cardiovascular disease (CVD) risk using available tools to guide treatment intensity 1
• Obtain baseline labs: serum creatinine with eGFR, urine albumin-to-creatinine ratio, fasting lipid panel, fasting glucose, and 12-lead ECG 2
• Screen for secondary hypertension in adults diagnosed before age 40 (except obese young adults, who should first be evaluated for obstructive sleep apnea) 1
• Screen all patients with difficult-to-control or resistant hypertension for primary aldosteronism using aldosterone-to-renin ratio 1

Treatment Algorithm by BP Category

Elevated BP (120-139/70-89 mmHg)

Low/Medium CVD Risk (<10% over 10 years):

• Initiate lifestyle modifications alone 1
• Reassess BP after 3 months 1

High CVD Risk:

• Start lifestyle modifications immediately 1
• After 3 months, if confirmed BP remains ≥130/80 mmHg, add pharmacological treatment 1

Confirmed Hypertension (≥140/90 mmHg)

• Initiate both lifestyle modifications AND pharmacological treatment promptly, regardless of CVD risk 1
• Start with combination therapy (two drugs) for most patients 1

Pharmacological Treatment Strategy

First-Line Combination Therapy

Preferred initial regimen: RAS blocker (ACE inhibitor OR angiotensin receptor blocker) + dihydropyridine calcium channel blocker OR thiazide/thiazide-like diuretic (chlorthalidone or indapamide) 1

• Use fixed-dose single-pill combinations to improve adherence 1
• Thiazide/thiazide-like diuretics have demonstrated the most effective reduction of BP and CVD events 1

Exceptions to combination therapy:

• Patients aged ≥85 years 1
• Symptomatic orthostatic hypotension 1
• Moderate-to-severe frailty 1
• Elevated BP (not hypertension) with concomitant indication for treatment 1

Treatment Escalation

If BP not controlled on two-drug combination:

• Escalate to three-drug combination: RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 1

Resistant hypertension (BP ≥130/80 mmHg on ≥3 drugs at maximum tolerated doses):

• Add spironolactone as fourth-line agent 2
• Exclude pseudo-resistance: verify accurate BP measurement, rule out white-coat effect, confirm medication adherence 1

Medications to Avoid or Reserve

• Do NOT combine two RAS blockers (ACE inhibitor + ARB together) 1
• Reserve beta-blockers for specific indications: angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control 1

Blood Pressure Targets

Standard target for most adults: Systolic BP 120-129 mmHg 1, 2

• Diastolic BP target: <80 mmHg but not <70 mmHg to avoid organ hypoperfusion 2
• If target cannot be tolerated, apply the "as low as reasonably achievable" (ALARA) principle 1
• Achieve target BP within 3 months of treatment initiation 2

Special populations:

• Diabetes or CKD (eGFR >30 mL/min/1.73m²): Target systolic BP 120-129 mmHg 3
• Pregnancy (chronic or gestational hypertension): Lower BP below 140/90 mmHg but not below 80 mmHg diastolic 1
• Age ≥85 years: Continue treatment if well tolerated, same targets as younger adults if not frail 1, 3

Lifestyle Modifications

Implement immediately for all patients with elevated BP or hypertension 1:

Weight Management

• Target healthy BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 3
• Weight loss of 10 lbs (4.5 kg) reduces BP by 5-20 mmHg 1

Dietary Interventions

• Adopt Mediterranean or DASH diet (rich in fruits, vegetables, low-fat dairy, reduced saturated fat) - reduces BP by 8-14 mmHg 1, 3
• Restrict sodium to approximately 2 g/day (reduces BP by 2-8 mmHg) 1, 3
• Reduce free sugar consumption, especially sugar-sweetened beverages 3
• Increase dietary potassium 1

Physical Activity

• Engage in moderate-intensity aerobic exercise ≥150 minutes/week or brisk walking ≥30 minutes most days (reduces BP by 4-9 mmHg) 1, 3
• Include resistance training 3

Alcohol and Tobacco

• Limit alcohol to <100 g/week or preferably avoid completely (reduces BP by 2-4 mmHg) 1, 3
• Stop all tobacco use and refer to smoking cessation programs 3

Implementation and Monitoring

Medication Timing and Adherence

• Instruct patients to take medications at the most convenient time of day to establish habitual pattern 1
• Use multidisciplinary team approach: physicians, nurses, pharmacists, dietitians, physiotherapists 3
• Implement home BP monitoring to improve control and patient empowerment 1, 3

Follow-up Schedule

• Reassess BP and medication tolerance within 2-4 weeks of treatment initiation 2
• Titrate medications every 2-4 weeks until target BP achieved 2
• Annual cardiovascular risk reassessment including lipid management and diabetes screening 2

Long-term Management

• Maintain BP-lowering treatment lifelong, even beyond age 85 years, if well tolerated 1
• Intensive BP control does not increase risk of orthostatic hypotension, falls, or acute renal failure 1
• Intensive BP lowering may prevent or arrest cognitive decline in older adults 1

Critical Pitfalls to Avoid

• Delaying combination therapy in patients with confirmed hypertension ≥140/90 mmHg - start two drugs immediately 3
• Using monotherapy when combination therapy is more effective and recommended 3
• Combining ACE inhibitor + ARB - this is contraindicated 1
• Failing to confirm diagnosis with out-of-office measurements, leading to overtreatment of white-coat hypertension 2
• Missing secondary hypertension in young adults (<40 years) - comprehensive screening is mandatory 1
• Discontinuing treatment prematurely - treatment should be lifelong if tolerated 3
• Ignoring lifestyle modifications - these enhance pharmacological therapy effectiveness and have additive BP-lowering effects 1