What is a comprehensive guide for managing hypertension as a provider?

Comprehensive Guide for Managing Hypertension

Start all patients with confirmed hypertension on lifestyle modifications immediately, and initiate pharmacologic therapy based on blood pressure level and cardiovascular risk—high-risk patients (CVD, CKD, diabetes, or organ damage) require immediate drug treatment, while low-moderate risk patients should begin medications after 3-6 months if BP remains elevated. 1

Diagnosis and Confirmation

Initial Blood Pressure Measurement

• Use a validated automated upper arm cuff device with appropriate cuff size for the individual patient 1
• At the first visit, measure BP in both arms simultaneously; if there is a consistent difference, use the arm with the higher BP for all subsequent measurements 1
• Base the diagnosis on the average of 2-3 readings taken on separate occasions 1

Diagnostic Thresholds

• Office BP ≥130/85 mmHg: Confirm with home or ambulatory BP monitoring before diagnosing hypertension 1
• Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms hypertension 1
• Office BP <130/85 mmHg: Remeasure after 3 years 1

Hypertension Classification

• Grade 1 Hypertension: 140-159/90-99 mmHg 1
• Hypertension requiring treatment: BP ≥140/90 mmHg (or ≥130/80 mmHg in high-risk patients) 1

Initial Evaluation

Essential Workup

• Assess for target organ damage (cardiac, renal, neurologic) 1
• Screen for secondary hypertension if clinically indicated (accounts for <10% of cases) 2
• Calculate 10-year cardiovascular disease risk using SCORE2 or SCORE2-OP 1
• Identify comorbidities: CVD, CKD, diabetes, heart failure 1

Treatment Initiation Strategy

Lifestyle Modifications (All Patients)

Start immediately for all patients with BP ≥130/85 mmHg 1:

• Weight loss: If overweight or obese 3
• Dietary sodium reduction: <2.3 g/day sodium 3
• Potassium supplementation: Increase dietary potassium intake 3
• Physical activity: Regular aerobic exercise 3
• Alcohol limitation: Moderate or eliminate consumption 3
• Healthy dietary pattern: DASH diet or Mediterranean diet 3

Pharmacologic Therapy Timing

• Immediate drug therapy: High-risk patients with CVD, CKD, diabetes, or organ damage 1
• Delayed drug therapy (3-6 months): Low-moderate risk patients—start medications only if BP remains elevated after lifestyle intervention 1

First-Line Pharmacologic Treatment

Non-Black Patients

Step 1: Start low-dose ACE inhibitor or ARB 1, 4

• Example: Lisinopril 10 mg once daily 4

Step 2: Add dihydropyridine calcium channel blocker (DHP-CCB) 1

• Example: Amlodipine 5-10 mg once daily 5

Step 3: Increase both medications to full dose 1

Step 4: Add thiazide-like diuretic 1

• Prefer chlorthalidone over hydrochlorothiazide for better 24-hour BP control 5

Step 5: Add spironolactone 25-50 mg daily; if not tolerated or contraindicated, use amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1, 5

Black Patients

Step 1: Start low-dose ARB + DHP-CCB OR DHP-CCB + thiazide-like diuretic 1

• Combination therapy is more effective than ACE inhibitor/ARB monotherapy in this population 5

Step 2: Increase to full dose 1

Step 3: Add the missing component (diuretic or ACE inhibitor/ARB) 1

Step 4: Add spironolactone or alternative fourth-line agent 1

Pediatric Patients (≥6 years)

• Starting dose: 0.07 mg/kg once daily (maximum 5 mg) 4
• Maximum dose: 0.61 mg/kg once daily (maximum 40 mg) 4
• Not recommended if GFR <30 mL/min/1.73m² 4

Blood Pressure Targets

General Population

• Target BP <130/80 mmHg for most adults 1
• Alternative acceptable target: <140/90 mmHg, with goal to reduce BP by at least 20/10 mmHg 1

Elderly Patients

• Individualize targets based on frailty status 1
• For adults ≥65 years: Target SBP <130 mmHg if tolerated 3

Special Populations

• Diabetes or CKD: Target <130/80 mmHg 1
• Heart failure: Start with 5 mg lisinopril once daily (or 2.5 mg if sodium <130 mEq/L), titrate to maximum 40 mg daily 4
• Post-MI: Start within 24 hours if hemodynamically stable; initial dose 5 mg, continue for at least 6 weeks 4

Monitoring and Follow-Up

Timeline for BP Control

• Achieve target BP within 3 months of treatment initiation or modification 1, 5
• Reassess BP within 2-4 weeks after adding or adjusting medication 5

Ongoing Monitoring

• Check BP control regularly to maintain target 1
• Assess medication adherence using a no-blame approach 1
• Monitor for adverse effects and adjust therapy accordingly 1

Resistant Hypertension Management

Definition

BP remains uncontrolled despite use of 3 or more antihypertensive agents at optimal doses, including a diuretic 2

Evaluation Steps

1. Rule out pseudoresistance: Confirm with home or ambulatory BP monitoring 2
2. Check medication adherence: Most apparent resistant hypertension is due to non-adherence 1
3. Identify interfering substances: NSAIDs, decongestants, excessive alcohol, illicit drugs 5, 2
4. Screen for secondary causes: Renal artery stenosis, primary aldosteronism, pheochromocytoma, Cushing's syndrome 2

Treatment Algorithm

Step 1: Optimize diuretic therapy—switch from hydrochlorothiazide to chlorthalidone or indapamide 1

Step 2: Add spironolactone 25-50 mg daily as preferred fourth-line agent 1, 5

• Reduces BP by average 25/12 mmHg even without biochemical aldosterone excess 5, 2

Step 3: If spironolactone contraindicated or not tolerated, use amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Step 4: In CKD with creatinine clearance <30 mL/min, use loop diuretics instead of thiazides 5

Step 5: Refer to hypertension specialist if BP remains uncontrolled 1

Hypertensive Crisis Management

Hypertensive Emergency (SBP >180 or DBP >120 mmHg with end-organ damage)

• Admit to ICU immediately 6
• Use short-acting IV antihypertensives: Labetalol, esmolol, fenoldopam, nicardipine, or clevidipine 6
• Reduce BP within hours (not minutes) to prevent ischemic complications 6
• Avoid: Immediate-release nifedipine, hydralazine 6
• Use sodium nitroprusside with caution due to toxicity risk 6

Hypertensive Urgency (Severe hypertension without end-organ damage)

• Treat as outpatient with oral antihypertensives 6
• Reduce BP over days, not hours 6

Optimizing Treatment Adherence

Medication Strategies

• Use once-daily dosing with long-acting medications 1
• Prescribe single-pill combinations whenever feasible 1
• Conduct medication reviews at appropriate intervals to identify adverse effects and optimize dosing 1

Patient Engagement

• Implement shared decision-making: Discuss CVD risk, treatment benefits/harms, and patient preferences 1
• Use motivational interviewing to enhance adherence 1
• Encourage home BP monitoring with validated devices 1
• Provide written and verbal instructions about medication use and lifestyle modifications 1

System-Level Interventions

• Implement team-based care with pharmacists, nurses, and other healthcare professionals 1
• Use telehealth strategies for remote monitoring and patient communication 1
• Employ electronic health records and patient registries to identify uncontrolled hypertension 1
• Reduce medication copayments when possible to improve adherence 1

Common Pitfalls to Avoid

Measurement Errors

• Using incorrect cuff size leads to inaccurate readings 1
• Diagnosing hypertension based on single office reading without confirmation 1

Treatment Errors

• Starting multiple medications simultaneously in low-risk patients 1
• Using hydrochlorothiazide instead of chlorthalidone in resistant hypertension 5
• Failing to assess adherence before escalating therapy 1
• Continuing NSAIDs in patients with resistant hypertension 5

Monitoring Errors

• Not achieving target BP within 3 months of treatment modification 1
• Failing to individualize BP targets in elderly or frail patients 1

Referral Indications

Refer to hypertension specialist when: 1

• BP remains uncontrolled despite optimized 4-drug regimen
• Suspected secondary hypertension requiring specialized evaluation
• Recurrent hypertensive emergencies
• Complex comorbidities requiring specialized management