What is the best course of treatment for a patient with hypertension (blood pressure of 158/85 mmHg)?

Blood Pressure Management for 158/85 mmHg

For a patient with blood pressure of 158/85 mmHg, you should initiate pharmacological therapy immediately with a single antihypertensive agent, as this represents Grade 2 hypertension (≥160/100 mmHg systolic or ≥140/90 mmHg with cardiovascular risk factors), and lifestyle modifications alone are insufficient at this level. 1

Initial Assessment and Confirmation

• Confirm the elevated reading by obtaining at least two additional measurements using a validated device with appropriate cuff size to rule out measurement error 2
• Consider home blood pressure monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) to confirm sustained hypertension and exclude white-coat hypertension 3, 2
• Assess for secondary causes of hypertension if there are concerning features such as young age, severe elevation, or resistance to therapy 2, 4

Pharmacological Treatment Strategy

For Non-Black Patients:

• Start with an ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily) as first-line therapy 2, 5
• Alternative first-line options include a thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) or calcium channel blocker (amlodipine 5 mg daily) 5, 6

For Black Patients:

• Start with a calcium channel blocker (amlodipine 5-10 mg daily) or thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) as these are more effective than ACE inhibitors/ARBs in this population 3, 2
• Consider initial dual therapy with a calcium channel blocker plus thiazide diuretic for Black patients with Grade 2 hypertension 2

Blood Pressure Targets and Timeline

• Target blood pressure is <130/80 mmHg for most adults under 65 years, with <130 mmHg systolic for those ≥65 years 1, 5
• Initial goal should be to reduce blood pressure by at least 20/10 mmHg 2
• Aim to achieve target blood pressure within 3 months of initiating therapy 1, 2

Lifestyle Modifications (Concurrent with Medication)

• Weight loss if overweight or obese through caloric restriction 1
• Sodium restriction to <2,300 mg/day (ideally <2,000 mg/day) 1, 5
• DASH-style eating pattern with 8-10 servings of fruits and vegetables daily and increased potassium intake 1, 5
• Regular physical activity and aerobic exercise 1, 5
• Moderate or eliminate alcohol consumption (limit to <100 g/week) 1, 5

These lifestyle interventions can provide additive blood pressure reductions of 10-20 mmHg and enhance medication effectiveness 1

Monitoring and Follow-up

• Schedule follow-up within 2-4 weeks after initiating therapy to assess response, medication adherence, and side effects 3, 2
• Monitor for specific adverse effects based on drug class: cough and hyperkalemia with ACE inhibitors, hyperkalemia with ARBs, hypokalemia and hyperuricemia with thiazides, and peripheral edema with calcium channel blockers 3
• Check serum potassium and creatinine 2-4 weeks after starting ACE inhibitor/ARB or thiazide diuretic 3

When to Escalate Therapy

• If blood pressure remains ≥140/90 mmHg after 2-4 weeks on monotherapy at optimal dose, add a second agent from a different class 1, 3
• The preferred two-drug combinations are: ACE inhibitor/ARB + calcium channel blocker, ACE inhibitor/ARB + thiazide diuretic, or calcium channel blocker + thiazide diuretic 3, 5
• If blood pressure remains uncontrolled on two drugs, add a third agent to achieve triple therapy (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1, 3

Critical Pitfalls to Avoid

• Do not delay pharmacological treatment at this blood pressure level—lifestyle modifications alone are insufficient for Grade 2 hypertension 1, 2
• Do not combine an ACE inhibitor with an ARB, as this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit 1, 3
• Do not assume treatment failure without first confirming medication adherence, as non-adherence is the most common cause of apparent treatment resistance 3, 7
• Avoid NSAIDs and other interfering substances that can elevate blood pressure and reduce antihypertensive efficacy 7, 4

Special Considerations

• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, target blood pressure <130/80 mmHg is particularly important to reduce cardiovascular events and stroke risk 1
• Consider referral to a hypertension specialist if blood pressure remains uncontrolled despite three medications at optimal doses, or if resistant hypertension develops 3, 2