What are the initial and subsequent treatment recommendations for managing hypertension?

Hypertension Management

Initial Treatment Strategy

For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications and pharmacological therapy simultaneously—do not delay medication while attempting lifestyle changes alone. 1

Blood Pressure-Based Treatment Approach

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

• Start with a single antihypertensive agent (ACE inhibitor, ARB, thiazide-like diuretic, or calcium channel blocker) 1, 2
• Lisinopril 10 mg once daily is an appropriate initial ACE inhibitor dose 3

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

• Begin with two-drug combination therapy from different classes immediately 1, 2
• Preferred combinations include:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker 1
  • RAS blocker + thiazide/thiazide-like diuretic 1
• Single-pill combinations are preferred to improve adherence 2

Special Population Considerations for Initial Therapy

For Black patients:

• Use ARB + dihydropyridine calcium channel blocker, or calcium channel blocker + thiazide/thiazide-like diuretic 2
• ACE inhibitors have reduced efficacy as monotherapy in this population 2

For patients with specific comorbidities:

• Coronary artery disease: ACE inhibitor or ARB as first-line 1, 2
• Albuminuria (UACR ≥30 mg/g): Include ACE inhibitor or ARB to reduce progressive kidney disease 1, 2
• Heart failure with reduced ejection fraction: ACE inhibitor (or ARB if intolerant) + beta-blocker + MRA + SGLT2 inhibitor 1
• Heart failure with preserved ejection fraction: SGLT2 inhibitors 1

Comprehensive Lifestyle Modifications

All patients with BP >120/80 mmHg should receive counseling on the following interventions, which are implemented alongside medications: 1, 4

• Weight loss: Achieve and maintain healthy body mass index through caloric restriction 2
• DASH diet: Emphasize 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products 1, 2
• Sodium restriction: Limit intake to <2,300 mg/day 2
• Increased potassium: Consume 8-10 servings/day of potassium-rich fruits and vegetables 2
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 2
• Smoking cessation: Recommended for all patients 2

Target Blood Pressure Goals

For adults <65 years:

• Target systolic BP: 120-129 mmHg 1, 2
• Target diastolic BP: <80 mmHg 1

For adults ≥65 years:

• Target systolic BP: 130-139 mmHg (more conservative due to tolerability concerns) 1

For patients with diabetes, chronic kidney disease, or established cardiovascular disease:

• Target BP: <130/80 mmHg 2

Medication Titration and Escalation

If BP is not controlled on initial therapy: 1

1. Increase to full doses before adding additional agents 1

   • Lisinopril can be titrated from 10 mg to 20-40 mg daily (usual range 20-40 mg/day) 3
   • Doses up to 80 mg have been used but provide no greater effect 3

2. If BP remains uncontrolled on two drugs at full doses:

   • Add a third agent to create the standard three-drug regimen: RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic 1

3. Important diuretic consideration:

   • Chlorthalidone or indapamide are preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcome data 2
   • If adding hydrochlorothiazide to lisinopril, use 12.5 mg initially 3
   • After adding a diuretic, the lisinopril dose may be reduced; recommended starting dose with concurrent diuretic is 5 mg once daily 3

Resistant Hypertension Management

Resistant hypertension is defined as BP ≥140/90 mmHg despite appropriate lifestyle management plus three antihypertensive drugs (including a diuretic) at adequate doses. 1

Treatment algorithm:

1. Ensure the three-drug combination is optimized at full doses 1
2. Add spironolactone 25 mg daily as first-line fourth agent 1, 2
3. Beta-blockers and alpha-blockers are fourth- or fifth-line agents used only when spironolactone is not tolerated or contraindicated 2

Monitoring and Follow-Up

Initial follow-up:

• Recheck BP in 1 month after initiating or changing therapy 1, 2
• Goal is to achieve BP control within 3 months 1, 2

Laboratory monitoring when using RAS blockers or MRAs:

• Check serum creatinine and potassium 7-14 days after initiation or dose changes 1, 2
• Monitor for hypokalemia when using diuretics 2

Ongoing follow-up:

• Continue every 1-3 months until BP is controlled 2

Critical Pitfalls to Avoid

Contraindications:

• ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors are absolutely 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 due to acute renal failure risk 2

Common errors:

• Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with BP ≥140/90 mmHg 2
• Do not use beta-blockers as initial therapy unless a specific indication exists (heart failure, coronary disease) 2
• Use thiazides cautiously in patients with gout or history of acute gout 2