What are the initial recommendations for blood pressure (BP) management?

Initial Blood Pressure Management

For adults with confirmed hypertension (BP ≥140/90 mmHg), initiate combination pharmacological therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide-like diuretic, preferably as a single-pill combination, alongside lifestyle modifications. 1, 2

Confirm the Diagnosis First

• Verify hypertension using out-of-office measurements to exclude white coat hypertension before starting pharmacological therapy 1, 2, 3
• Home BP monitoring threshold: ≥135/85 mmHg 3
• 24-hour ambulatory BP monitoring threshold: ≥130/80 mmHg 3
• Proper measurement technique requires: patient seated quietly for 5 minutes, feet flat on floor, arm supported at heart level, appropriately sized cuff, averaging ≥2 measurements, and avoiding caffeine/exercise/smoking for 30 minutes prior 3

Risk Stratification Determines Treatment Intensity

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

• For 10-year CVD risk ≥10%: Start intensive lifestyle modifications for 3 months, then add pharmacological therapy if confirmed BP remains ≥130/80 mmHg 1, 2, 3
• For 10-year CVD risk 5-<10% with risk modifiers: Same approach as above 1
• For 10-year CVD risk <10%: Lifestyle modifications alone with BP reassessment in 3-6 months 1

Stage 1 Hypertension (140-159/90-99 mmHg)

• With 10-year ASCVD risk ≥10%: Immediate combination of lifestyle modifications plus pharmacological therapy 1
• With 10-year ASCVD risk <10%: Lifestyle modifications first, reassess in 3-6 months 1

Stage 2 Hypertension (≥160/100 mmHg)

• Initiate two-drug combination therapy immediately along with lifestyle modifications 1, 2
• Refer to or evaluate by primary care provider within 1 month 1
• Repeat BP evaluation in 1 month 1

Hypertensive Urgency (≥180/110 mmHg)

• Prompt evaluation and antihypertensive drug treatment within 1 week, with rapidity dependent on presence of target organ damage 1, 2

First-Line Pharmacological Therapy

Preferred Initial Combinations

The cornerstone of initial therapy is a two-drug combination using:

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

Single-Pill Combinations Strongly Preferred

• Fixed-dose single-pill combinations improve adherence and should be used whenever possible 2
• These combinations have demonstrated the most effective reduction in BP and cardiovascular events 2

Specific Drug Dosing Examples

• Lisinopril: Start 10 mg once daily for hypertension; adjust to usual range of 20-40 mg daily based on response 4
• Amlodipine: May be used alone or in combination with other antihypertensive agents 5

When NOT to Use Combination Therapy Initially

• Consider monotherapy only in very low-risk patients with stage 1 hypertension or those with BP just above 140/90 mmHg 1
• Never combine two RAS blockers (ACE inhibitor + ARB) - this is contraindicated 2

Beta-Blockers Are NOT First-Line

• Reserve beta-blockers for specific compelling indications: post-MI, angina, heart failure with reduced ejection fraction, or heart rate control 1, 2
• They have similar BP-lowering efficacy but inferior cardiovascular outcomes compared to other first-line agents 1

Lifestyle Modifications (Essential for ALL Patients)

Initiate evidence-based lifestyle interventions for all patients with BP >120/80 mmHg: 3, 6

Weight Management

• Target BMI 20-25 kg/m² 2
• Waist circumference <94 cm in men, <80 cm in women 2
• Weight loss is among the most effective lifestyle interventions 6, 7, 8

Dietary Modifications

• Adopt DASH (Dietary Approaches to Stop Hypertension) diet - this may be the single most effective dietary intervention 2, 6, 9, 7
• Mediterranean diet is also recommended 2
• Sodium restriction to <2,300 mg/day 3, 6, 9
• Increase potassium intake through fruits and vegetables 3
• Restrict free sugar consumption, especially sugar-sweetened beverages 2

Alcohol Limitation

• Limit to ≤2 standard drinks/day (maximum 14/week for men, 9/week for women), or preferably avoid completely 2, 3, 6
• Alcohol restriction is one of the most effective lifestyle modifications 6

Physical Activity

• Engage in regular aerobic and resistance training 2, 6
• Regular exercise significantly reduces BP in both normotensive and hypertensive individuals 10, 7

Tobacco Cessation

• Stop all tobacco use and refer to smoking cessation programs 2

Timing of Lifestyle Intervention

• For elevated BP or stage 1 hypertension with low CVD risk: Trial lifestyle modifications for 3-6 months before adding medications 1, 6
• For stage 2 hypertension or high CVD risk: Start lifestyle modifications simultaneously with pharmacological therapy 1, 2

Blood Pressure Targets

Target systolic BP to 120-129 mmHg for most adults <65 years if well tolerated 1, 2, 3

• For adults ≥65 years: Target 130-139 mmHg systolic 3
• For patients with diabetes or CKD (eGFR >30 mL/min/1.73m²): Target 120-129 mmHg systolic 1, 2, 3
• If target cannot be achieved due to poor tolerance: Use "as low as reasonably achievable" (ALARA) principle 2
• Diastolic target: 70-79 mmHg for most patients 1

Treatment Escalation Algorithm

If BP Not Controlled on Two-Drug Combination

Escalate to three-drug combination: RAS blocker + dihydropyridine calcium channel blocker + thiazide-like diuretic, preferably as single-pill combination 2

If BP Still Not Controlled (Resistant Hypertension)

• Add spironolactone as fourth agent 3
• Screen for secondary hypertension, especially in adults diagnosed before age 40 2

Monitoring and Follow-Up

Initial Follow-Up Intervals

• Stage 2 hypertension or very high BP: Recheck in 1 month 1, 3
• Stage 1 hypertension with high CVD risk: Recheck in 1 month 1
• Elevated BP or stage 1 hypertension with low CVD risk: Recheck in 3-6 months 1
• Normal BP: Annual screening is reasonable 1

Laboratory Monitoring

• Check serum creatinine and potassium 7-14 days after starting ACE inhibitors, ARBs, or diuretics 3
• Achieve BP control within 3 months of initiating therapy 3

Long-Term Management

• Maintain BP-lowering treatment lifelong if tolerated, even beyond age 85 years 2
• Home BP monitoring improves control and patient empowerment 2
• Take medications at the most convenient time of day to establish habitual pattern 2

Special Populations Requiring Modified Approach

Defer Pharmacological Treatment Until BP >140/90 mmHg in:

• Pre-treatment symptomatic orthostatic hypotension 1
• Age ≥85 years 1
• Moderate-to-severe frailty 1
• Limited life expectancy (<3 years) 1
• eGFR <30 mL/min/1.73m² 1

Patients with CKD

• For moderate-to-severe CKD with confirmed BP ≥130/80 mmHg: Use lifestyle optimization plus BP-lowering medication 2
• SGLT2 inhibitors are recommended for hypertensive patients with CKD and eGFR >20 mL/min/1.73m² 2
• RAS blockers are more effective at reducing albuminuria than other agents 2

Common Pitfalls to Avoid

• Delaying combination therapy in patients with confirmed hypertension ≥140/90 mmHg - this is the most common error 2
• Using monotherapy when combination therapy would be more effective 2
• Failing to confirm diagnosis with out-of-office measurements, leading to treatment of white coat hypertension 1, 3
• Discontinuing treatment prematurely - BP-lowering treatment should be maintained lifelong if tolerated 2
• Not screening for orthostatic hypotension before starting or intensifying treatment 2
• Therapeutic inertia - failing to add pharmacological therapy after 3 months of unsuccessful lifestyle intervention 1

Implementation Strategies

• Use multidisciplinary approaches including physicians, nurses, pharmacists, dietitians, and physiotherapists 2
• Address the five dimensions of adherence: socio-economic factors, health system factors, therapy-related factors, condition-related factors, and patient-related factors 2
• Provide clear written information to support lifestyle modifications 1