What are the initial management recommendations for hypertension according to new guidelines?

Initial Management of Hypertension According to New Guidelines

Begin all patients with confirmed hypertension (BP ≥140/90 mmHg) on both lifestyle modifications AND pharmacological therapy simultaneously—do not delay drug treatment for a trial of lifestyle changes alone. 1, 2

Confirming the Diagnosis

• Confirm hypertension using out-of-office measurements before initiating treatment: home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg). 2
• Measure BP at multiple visits with proper technique: seated position, arm at heart level, validated device, at least two measurements per visit. 1
• Check standing BP in elderly and diabetic patients to exclude orthostatic hypotension. 1

Lifestyle Modifications (Start Immediately for All Patients)

Implement these evidence-based interventions alongside medications—they enhance drug efficacy and should never be used as a reason to delay pharmacotherapy: 2, 3

• Weight loss to ideal body weight through caloric restriction for overweight individuals. 1, 2, 3
• DASH diet pattern: 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products. 1, 2, 4
• Sodium restriction to <2,300 mg/day; eliminate table salt use. 1, 2
• Increased potassium intake through dietary sources (fruits and vegetables). 2, 3
• Physical activity: at least 150 minutes/week of moderate-intensity aerobic exercise (brisk walking, not weight training). 1, 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women. 1, 2
• Smoking cessation for all patients. 1, 2

Initial Pharmacological Therapy

For BP 140-159/90-99 mmHg (Stage 1):

Start with a single antihypertensive agent from first-line options: 2

• ACE inhibitor (lisinopril 10 mg daily) OR 2, 5
• ARB OR 2
• Thiazide-like diuretic (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide) OR 2, 6, 3
• Dihydropyridine calcium channel blocker (amlodipine 5 mg daily). 2, 3

For non-Black patients, prefer starting with an ACE inhibitor or ARB. 2

For Black patients, start with either an ARB + calcium channel blocker OR calcium channel blocker + thiazide diuretic (ACE inhibitors have reduced efficacy as monotherapy in this population). 2

For BP ≥160/100 mmHg or BP ≥150/90 mmHg (Stage 2):

Initiate combination therapy with TWO antihypertensive agents from different classes, preferably as a single-pill combination: 1, 2

Recommended two-drug combinations:

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker OR 1, 2
• RAS blocker + thiazide/thiazide-like diuretic. 1, 2

Specific example regimens:

• Chlorthalidone 12.5-25 mg + lisinopril 10 mg daily OR 2, 5, 6
• Chlorthalidone 12.5-25 mg + amlodipine 5 mg daily. 2

Blood Pressure Targets

Target BP <130/80 mmHg for most adults under 65 years. 2, 3

Target systolic BP 120-129 mmHg for most adults when treatment is well tolerated (this is the optimal goal per the most recent European guidelines). 2

For patients ≥65 years: target systolic BP <130 mmHg. 2

For patients with diabetes, chronic kidney disease, or established cardiovascular disease: target BP <130/80 mmHg. 1, 2

Titration Strategy

• Recheck BP in 1 month after initiating therapy. 2
• Allow at least 4 weeks to observe full response before dose adjustments unless urgent BP lowering is needed. 1
• Titrate to full dose of initial agent(s) before adding additional medications. 2
• Lisinopril can be titrated from 10 mg to 20-40 mg daily (usual dosage range). 2, 5

If BP not controlled with two drugs after 3 months, escalate to three-drug combination: 2

• ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic. 2

If BP remains uncontrolled on three optimized drugs (resistant hypertension), add:

• Spironolactone 25 mg daily as the fourth-line agent. 2, 7
• Beta-blockers and alpha-blockers are reserved as fifth-line agents when spironolactone is contraindicated or not tolerated. 2

Critical Contraindications and Monitoring

Absolute contraindications:

• ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors are contraindicated in pregnancy or women planning pregnancy due to fetal injury and death. 2
• Avoid ACE inhibitors in patients with history of angioedema. 2
• Avoid ACE inhibitors/ARBs in severe bilateral renal artery stenosis (risk of acute renal failure). 2

Monitoring requirements:

• Check serum creatinine and potassium 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 2
• Monitor for hypokalemia when using diuretics. 2
• Use thiazides cautiously in patients with gout unless on uric acid-lowering therapy. 2

Common Pitfalls to Avoid

• Do NOT delay pharmacotherapy for a 3-6 month trial of lifestyle modification in patients with BP ≥140/90 mmHg—current evidence favors simultaneous initiation. 2
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available—longer-acting thiazide-like diuretics have superior cardiovascular outcome data. 2, 3
• Do NOT use beta-blockers as initial therapy unless specific indications exist (heart failure, coronary artery disease, post-MI). 2
• Do NOT use thiazide + beta-blocker combination in patients at high risk for diabetes (strong family history, obesity, impaired glucose tolerance, metabolic syndrome, South Asian or African-Caribbean descent) due to increased diabetes incidence. 1

Special Population Considerations

Patients with coronary artery disease: Use ACE inhibitor or ARB as first-line therapy. 2

Patients with albuminuria (UACR ≥30 mg/g): Initiate ACE inhibitor or ARB to reduce progressive kidney disease risk. 2

Patients with heart failure: Add beta-blockers in addition to other agents. 2

Elderly patients >80 years: Consider initiating treatment only when office systolic BP ≥160 mmHg. 1