What is the recommended management for a patient with new onset hypertension?

Management of New Onset Hypertension in a Black Patient

For a Black patient with new onset hypertension, initiate combination therapy with a calcium channel blocker (CCB) plus either a thiazide diuretic or an ACE inhibitor/ARB, targeting a blood pressure of 120-129/<80 mmHg, alongside comprehensive lifestyle modifications. 1

Initial Assessment and Diagnosis

Confirm the Diagnosis

• Verify hypertension with out-of-office measurements (home or ambulatory BP monitoring) if office BP is 130-159/85-99 mmHg to exclude white coat hypertension 1
• If office BP ≥160/100 mmHg, confirm within days to weeks, preferably with home or ambulatory monitoring 1
• Exclude hypertensive emergency if BP ≥180/110 mmHg 1

Essential Baseline Testing

• Serum creatinine with eGFR and urine albumin-to-creatinine ratio to assess kidney function 1
• Fasting glucose and hemoglobin A1C (A1C detects pre-diabetes even with normal fasting glucose) 1
• Lipid profile, CBC, TSH, and electrocardiogram 1
• Screen for secondary hypertension if: age <40 years (unless obese), abrupt onset, resistant hypertension, or unprovoked hypokalemia 1

Lifestyle Modifications (Initiate Immediately)

All patients require aggressive lifestyle intervention regardless of medication decisions: 1

Dietary Changes

• Sodium restriction to <1500 mg/day (approximately 2g sodium = 5g salt/day) 1
• Increase dietary potassium to 3500-5000 mg/day 1
• Adopt DASH or Mediterranean diet rich in fruits, vegetables, whole grains, and low-fat dairy products 1
• Restrict free sugar consumption to <10% of energy intake; eliminate sugar-sweetened beverages 1

Weight and Physical Activity

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Minimum 150 minutes/week of moderate-intensity aerobic exercise (or 75 minutes vigorous) 1
• Add low-to-moderate intensity resistance training 2-3 times/week 1

Alcohol and Tobacco

• Limit alcohol to ≤100g/week (≤2 drinks/day for men, ≤1 for women); preferably avoid completely 1
• Complete smoking cessation with referral to cessation programs 1

Pharmacological Treatment Strategy

When to Start Medications

Initiate drug therapy promptly in the following scenarios: 1

• Confirmed BP ≥140/90 mmHg: Start medications immediately regardless of CVD risk 1
• BP 130-139/80-89 mmHg with high CVD risk (≥10% 10-year risk, established CVD, diabetes, CKD, or hypertension-mediated organ damage): Start after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 1
• BP 120-139/70-89 mmHg with low-medium CVD risk: Lifestyle modifications only 1

First-Line Drug Selection for Black Patients

Black patients have specific pharmacological considerations: 1

• Preferred initial combination: CCB (dihydropyridine) + thiazide diuretic 1
• Alternative combination: CCB + ACE inhibitor or ARB 1
• Avoid monotherapy with ACE inhibitors or ARBs as they have smaller BP effects in Black patients 1, 2

Standard First-Line Therapy (All Patients)

For most patients with confirmed hypertension (BP ≥140/90 mmHg), start with combination therapy: 1

• Preferred combinations:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB, OR
  • RAS blocker + thiazide/thiazide-like diuretic 1
• Use fixed-dose single-pill combinations to improve adherence 1
• First-line drug classes: ACE inhibitors, ARBs, dihydropyridine CCBs, thiazides/thiazide-like diuretics (chlorthalidone, indapamide) 1, 3, 4, 2

Exceptions to combination therapy (consider monotherapy): 1

• Age ≥85 years
• Symptomatic orthostatic hypotension
• Moderate-to-severe frailty
• Elevated BP (120-139/70-89 mmHg) with specific indication for treatment

Treatment Escalation

If BP not controlled on two-drug combination: 1

• Add third drug: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic (preferably single-pill combination) 1

If BP not controlled on three-drug combination (resistant hypertension): 1

• Add low-dose spironolactone (first choice) 1
• If spironolactone not tolerated: eplerenone, amiloride, higher-dose thiazide, or loop diuretic 1
• Alternative additions: bisoprolol or doxazosin 1

Never combine two RAS blockers (ACE inhibitor + ARB) 1

Blood Pressure Targets

Target treated systolic BP of 120-129 mmHg in most adults if well tolerated 1

• For adults <65 years: <130/80 mmHg 2
• For adults ≥65 years: systolic <130 mmHg 2
• If target not tolerated, use "as low as reasonably achievable" (ALARA) principle 1

Monitoring and Follow-Up

Initial Phase

• Follow monthly for medication titration until BP controlled 1
• Achieve BP control within 3 months 1
• Monitor for medication side effects and adherence 1

Maintenance Phase

• Annual follow-up for patients with controlled BP 1
• Every 3-6 months for elevated BP or stage 1 hypertension not on medications 1
• Repeat creatinine, eGFR, and urine ACR annually if moderate-to-severe CKD present 1

Critical Pitfalls to Avoid

• Do not delay pharmacological therapy in confirmed hypertension ≥140/90 mmHg; lifestyle changes alone are insufficient 1
• Do not use ACE inhibitor or ARB monotherapy as initial treatment in Black patients due to reduced efficacy 1
• Do not use beta-blockers as first-line therapy unless specific compelling indication (post-MI, heart failure, angina) 1
• Do not stop medications even beyond age 85 if well tolerated 1
• Do not rely solely on office BP measurements for diagnosis; confirm with out-of-office monitoring 1