What is the best treatment approach for a patient with hypertension?

Treatment Approach for Elevated Blood Pressure

For a patient with confirmed hypertension (BP ≥140/90 mmHg), initiate simultaneous combination therapy with lifestyle modifications plus a two-drug pharmacological regimen consisting of a RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker or thiazide diuretic, preferably as a single-pill combination. 1

Initial Assessment and Confirmation

• Confirm the diagnosis using out-of-office BP measurements (home BP monitoring ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg) rather than relying solely on office readings 1
• Perform routine investigations including urine strip test for blood and protein, serum electrolytes and creatinine, blood glucose, total:HDL cholesterol ratio, and 12-lead electrocardiograph 1
• Assess cardiovascular risk using 10-year CVD risk calculation and screen for target organ damage, diabetes, chronic kidney disease, or established CVD 1

Pharmacological Treatment Algorithm

For Confirmed Hypertension (BP ≥140/90 mmHg)

Start immediately with two-drug combination therapy rather than monotherapy 1:

• Preferred first-line combinations 1:

  • RAS blocker (ACE inhibitor like lisinopril or ARB like losartan) + dihydropyridine calcium channel blocker (amlodipine)
  • RAS blocker + thiazide/thiazide-like diuretic (hydrochlorothiazide or chlorthalidone)

• Use fixed-dose single-pill combinations when available to improve adherence 1

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

• If 10-year CVD risk ≥10% or high-risk conditions present (established CVD, diabetes, CKD, target organ damage): initiate combination pharmacological therapy plus lifestyle modifications 1
• If 10-year CVD risk <10% without high-risk conditions: lifestyle modifications alone with close monitoring 1

Stepwise Intensification for Uncontrolled BP

Step 1: Two-Drug Combination

Start with RAS blocker + calcium channel blocker or diuretic at appropriate doses 1, 2

Step 2: Three-Drug Combination

If BP remains uncontrolled after 3 months, escalate to triple therapy: RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 1

Step 3: Four-Drug Regimen

If BP still uncontrolled on triple therapy, add spironolactone 25-50mg daily as the preferred fourth agent 1

Step 4: Resistant Hypertension

If spironolactone is not effective or tolerated, consider eplerenone, beta-blocker (if not already indicated), centrally acting agent, alpha-blocker, hydralazine, or potassium-sparing diuretic 1

Lifestyle Modifications (Concurrent with Pharmacotherapy)

Implement all of the following simultaneously 1, 3, 2:

• Weight reduction to achieve BMI 20-25 kg/m² through reduced fat and total calorie intake 1, 2
• Dietary sodium restriction to <2g/day by eliminating excessively salty foods and limiting salt in cooking 1, 3, 2
• DASH diet pattern emphasizing increased fruit, vegetables, and potassium intake (most effective dietary intervention) 3, 2
• Alcohol limitation to <21 units/week for men, <14 units/week for women 1, 3
• Regular aerobic physical exercise (predominantly dynamic like brisk walking rather than isometric) designed to improve fitness 1, 2
• Smoking cessation to reduce overall cardiovascular risk 1, 3

Blood Pressure Targets

• General target: <140/90 mmHg minimum for most patients 1, 2
• Optimal target: 120-139 mmHg systolic if well tolerated 1
• Adults ≥65 years: SBP <130 mmHg 2
• Adults <65 years: <130/80 mmHg 2

Monitoring and Follow-Up

• See patients frequently (every 1-3 months) until BP is controlled 1
• Achieve target BP within 3 months of treatment initiation or modification 1
• Monitor serum potassium and creatinine 2-4 weeks after initiating RAS blockers or diuretics 4
• Confirm medication adherence at each visit, as non-adherence is the most common cause of apparent treatment resistance 5, 6

Critical Pitfalls to Avoid

• Never use monotherapy as initial treatment for confirmed hypertension (BP ≥140/90 mmHg) - combination therapy is recommended from the outset 1
• Never combine two RAS blockers (ACE inhibitor + ARB) - this increases adverse events without additional benefit 1
• Never delay pharmacological treatment while attempting lifestyle modifications alone in patients with confirmed hypertension - both should be initiated simultaneously 1
• Never add a fourth drug before optimizing doses of the three-drug combination 1
• Never assume treatment failure without first confirming adherence and ruling out secondary causes of hypertension 5, 6

Special Considerations

• Black patients: May require combination therapy from outset as monotherapy is often insufficient; diuretic + calcium channel blocker combinations may be more effective than RAS blocker-based regimens 4, 7
• Diabetic patients with renal impairment: RAS blockers are particularly indicated for renoprotection regardless of race 4
• Elderly patients (≥85 years): Consider starting with monotherapy if symptomatic orthostatic hypotension or moderate-to-severe frailty present 1
• Patients with compelling indications: Tailor drug selection based on comorbidities (e.g., ACE inhibitors for heart failure, beta-blockers post-MI) 8, 7