What is the management approach for a patient diagnosed with hypertension after two visits with elevated blood pressure?

Management of Hypertension After Two Elevated Blood Pressure Visits

For a patient with hypertension confirmed on two visits, immediately initiate both lifestyle modifications and pharmacological treatment if BP is ≥140/90 mmHg, regardless of cardiovascular risk status. 1

Confirming the Diagnosis

Before initiating treatment, confirm the diagnosis with out-of-office measurements whenever feasible:

• Use home blood pressure monitoring (HBPM) or 24-hour ambulatory blood pressure monitoring (ABPM) to confirm office readings, as this improves diagnostic accuracy and excludes white coat hypertension 1
• Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms hypertension 1
• If BP is ≥180/110 mmHg, exclude hypertensive emergency immediately 1
• For BP 160-179/100-109 mmHg, confirm within 1 month preferably with home or ambulatory monitoring 1

Cardiovascular Risk Assessment

Calculate 10-year cardiovascular disease risk using SCORE2 (ages 40-69) or SCORE2-OP (ages ≥70) to guide treatment intensity unless the patient already has established CVD, chronic kidney disease, diabetes, or hypertension-mediated organ damage 1. This risk stratification determines treatment urgency for patients with BP 130-139/80-89 mmHg (elevated BP category) 1.

Initial Workup

Perform baseline investigations to identify target organ damage and secondary causes:

• Urine dipstick for protein and blood 1
• Serum creatinine, eGFR, and electrolytes 1
• Fasting glucose and lipid profile 1
• 12-lead ECG to detect left ventricular hypertrophy 1
• Screen for secondary hypertension if diagnosed before age 40 (except obese patients—start with sleep apnea evaluation) 1
• Consider screening all hypertensive patients for primary aldosteronism with renin and aldosterone measurements 1

Lifestyle Modifications (Mandatory for All Patients)

Initiate these evidence-based interventions immediately 1:

• Aerobic exercise: At least 150 minutes/week of moderate-intensity activity (30 minutes, 5-7 days/week), plus resistance training 2-3 times/week 1
• Dietary sodium restriction: Reduce to <1500 mg/day 2
• Increase potassium intake: Target 3500-5000 mg/day through diet or potassium-enriched salt (75% NaCl/25% KCl), unless contraindicated by CKD or potassium-sparing medications 1, 2
• Weight management: Target BMI 20-25 kg/m² and waist circumference <102 cm (men) or <88 cm (women) 1
• Dietary pattern: Adopt DASH or Mediterranean diet with increased fruits and vegetables 2
• Alcohol limitation: <21 units/week for men, <14 units/week for women 1
• Restrict free sugar: Maximum 10% of energy intake; eliminate sugar-sweetened beverages 1

Pharmacological Treatment Strategy

When to Start Medications

Start drug therapy immediately for confirmed BP ≥140/90 mmHg, regardless of cardiovascular risk 1. For elevated BP (130-139/80-89 mmHg) with high CVD risk (≥10% over 10 years), start medications after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 1.

Initial Drug Selection

Begin with combination therapy using two drugs from different classes 1:

For non-Black patients:

• ACE inhibitor or ARB + calcium channel blocker (CCB) 1, 2
• Alternative: ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1

For Black patients:

• CCB + thiazide/thiazide-like diuretic 1, 2
• Alternative: ARB + CCB 2

Use single-pill combinations whenever possible to improve adherence 1, 2. Monotherapy may be considered only for low-risk Grade 1 hypertension, patients >80 years, or frail patients 1.

Specific Drug Recommendations

First-line agents include 3, 4, 5:

• Thiazide/thiazide-like diuretics: Chlorthalidone or hydrochlorothiazide
• ACE inhibitors: Lisinopril, enalapril
• ARBs: Candesartan, losartan
• Dihydropyridine CCBs: Amlodipine, extended-release nifedipine

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

Dose Titration and Escalation

• Titrate to full doses before adding additional agents 1
• If BP remains uncontrolled on two drugs, add a third agent: typically a RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1
• Fourth-line agent: Add spironolactone (mineralocorticoid receptor antagonist) or, if not tolerated, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Blood Pressure Targets

Target systolic BP of 120-129 mmHg in most adults if well tolerated 1, 2. This aggressive target reduces cardiovascular events by 20-30% for every 10 mmHg reduction 5.

• Minimum acceptable target: <140/90 mmHg 1
• For adults <65 years: <130/80 mmHg 5
• For adults ≥65 years: Systolic <130 mmHg (individualize based on frailty) 5
• If target 120-129 mmHg is poorly tolerated: Use "as low as reasonably achievable" (ALARA) principle 1

Monitoring and Follow-Up

• Achieve BP control within 3 months of initiating treatment 1, 2
• Follow monthly during medication titration until BP is controlled 2
• Once controlled: Annual follow-up with home BP monitoring 2
• Test for orthostatic hypotension before starting or intensifying medications (measure BP after 5 minutes sitting/lying, then at 1 and/or 3 minutes after standing) 1
• Maintain treatment lifelong, even beyond age 85 if well tolerated 1

Common Pitfalls to Avoid

• Do not delay pharmacological treatment for patients with BP ≥140/90 mmHg while attempting lifestyle modifications alone 1
• Do not use monotherapy as initial treatment for most patients—combination therapy is more effective 1
• Do not accept suboptimal BP control (<140/90 mmHg)—target 120-129 mmHg systolic when tolerated 1
• Check medication adherence before labeling as resistant hypertension; consider objective assessment (directly observed treatment or drug detection in blood/urine) 1
• Refer to hypertension specialist if BP remains uncontrolled on three or more drugs (resistant hypertension) 1