How should a patient with hypertension (blood pressure 188/90) be managed?

Management of Blood Pressure 188/90 mmHg

This patient requires immediate initiation of antihypertensive drug therapy, as the systolic blood pressure of 188 mmHg exceeds the threshold of 160 mmHg that mandates pharmacological intervention regardless of cardiovascular risk factors. 1

Urgency Assessment

This blood pressure does not constitute a hypertensive emergency requiring immediate hospitalization, as it falls below 220/120 mmHg and presumably lacks signs of acute end-organ damage (accelerated hypertension with grade III-IV retinopathy, transient ischemic attack, left ventricular failure). 1 However, this is Grade 2 hypertension requiring prompt outpatient management. 1, 2

Immediate Management Steps

Pharmacological Therapy - Required Now

Start combination antihypertensive therapy immediately, as blood pressure ≥160/100 mmHg mandates drug treatment without delay. 1

First-line drug options include: 1, 3

• ACE inhibitor (e.g., lisinopril 10-20 mg daily) OR ARB (e.g., candesartan) 1, 4
• Plus a calcium channel blocker (e.g., amlodipine 5-10 mg daily) 1, 5, 3
• Or a thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1, 2, 3

The 2024 ESC guidelines emphasize that most patients require at least two drugs to achieve blood pressure control, and single-pill combinations improve adherence. 1 At this blood pressure level (188/90), starting with dual therapy is appropriate rather than sequential monotherapy titration. 1, 2

Lifestyle Modifications - Concurrent with Medications

Implement all of the following lifestyle interventions immediately, as they complement pharmacological therapy and may reduce the number or dose of medications needed: 1

• Sodium restriction to <2 g/day and adopt DASH diet (high in vegetables, fruits, fish, nuts, unsaturated fatty acids, low-fat dairy; low in red meat) 1, 2
• Aerobic exercise: 150 minutes of moderate-intensity OR 75 minutes of vigorous-intensity per week, plus resistance training 2-3 times weekly 1
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Alcohol restriction: <14 units/week for men, <8 units/week for women (preferably avoid entirely) 1
• Smoking cessation if applicable 1

Blood Pressure Targets

The treatment goal is to achieve blood pressure <130/80 mmHg in most adults, with an optimal systolic target of 120-129 mmHg if well tolerated. 1, 2 This represents a more aggressive target than older guidelines, based on recent evidence showing cardiovascular benefit at lower blood pressure levels. 1

For patients ≥65 years, target systolic blood pressure to 130-139 mmHg. 1 More lenient targets (<140/90 mmHg) should be considered only for patients with symptomatic orthostatic hypotension, age ≥85 years, significant frailty, or limited life expectancy (<3 years). 1

Follow-Up Timeline

Schedule follow-up within 2-4 weeks to assess treatment response, check for adverse effects, and monitor renal function and electrolytes. 2 Allow at least 4 weeks to observe full drug response before further dose titration, unless more urgent blood pressure reduction is needed. 1

If blood pressure remains uncontrolled on two drugs, add a third agent from a different class (typically completing the ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic combination). 1, 3

If blood pressure remains uncontrolled on three drugs, add spironolactone (or eplerenone if not tolerated), followed by beta-blocker if needed. 1

Additional Considerations

Assess cardiovascular risk factors and consider: 1

• Aspirin 75 mg daily if age ≥50 years with controlled blood pressure and either target organ damage, diabetes, or 10-year cardiovascular disease risk ≥20% 1
• Statin therapy if 10-year cardiovascular disease risk ≥20% or if diabetes/established cardiovascular disease present, targeting LDL-C <70 mg/dL 1

Evaluate for secondary causes of hypertension if: 1

• Young age (<30 years requiring treatment)
• Sudden onset or worsening hypertension
• Resistant to three-drug regimen
• Hypokalemia with elevated/high-normal sodium (suggesting Conn's syndrome)
• Elevated creatinine, proteinuria, or hematuria

Consider home blood pressure monitoring to confirm office readings, assess treatment efficacy, and improve medication adherence. 1, 2

Common Pitfalls to Avoid

Do not use immediate-release nifedipine, hydralazine, or nitroglycerin for outpatient blood pressure management, as these are associated with unpredictable blood pressure drops and adverse outcomes. 6 These agents are reserved for specific inpatient hypertensive emergencies only.

Avoid beta-blocker plus thiazide diuretic combination in patients at high risk for diabetes (strong family history, obesity, impaired glucose tolerance, metabolic syndrome, South Asian or African-Caribbean descent), as this combination increases diabetes incidence. 1

Do not delay pharmacological therapy for a prolonged trial of lifestyle modifications alone at this blood pressure level—drug therapy is mandatory for systolic blood pressure ≥160 mmHg. 1