What is the stepwise approach to reduce elevated blood pressure from 150/90 mmHg?

Stepwise Blood Pressure Reduction for 150/90 mmHg

For blood pressure of 150/90 mmHg (Grade 1 hypertension), start lifestyle interventions immediately and initiate drug therapy now if you have high cardiovascular risk (CVD, CKD, diabetes, organ damage, or age 50-80 years); otherwise, start medication after 3-6 months if BP remains elevated despite lifestyle changes. 1

Immediate Actions

Confirm the Diagnosis

• Take at least 2 more BP readings at this visit using a validated device with appropriate cuff size 1
• Confirm with home BP monitoring (≥135/85 mmHg confirms hypertension) or 24-hour ambulatory monitoring (≥130/80 mmHg confirms hypertension) 1
• Remeasure in 2-3 office visits before finalizing diagnosis 1

Start Lifestyle Modifications Now (All Patients)

• Sodium restriction: Limit intake to <2g/day, which can reduce BP by 5-10 mmHg 1, 2
• Weight loss: Target BMI 20-25 kg/m² if overweight 1
• Physical activity: Regular aerobic exercise (150 minutes/week moderate intensity) 3, 4
• Dietary pattern: Adopt DASH diet emphasizing fruits, vegetables, low-fat dairy, reduced saturated fat 3
• Alcohol limitation: <100g/week 1
• Potassium supplementation: Increase dietary potassium intake 2, 3

These lifestyle changes provide additive BP reductions of 10-20 mmHg and enhance medication efficacy 1, 2

Drug Therapy Algorithm

Step 1: Initial Monotherapy

For Non-Black Patients:

• Start low-dose ACE inhibitor (e.g., lisinopril 10mg daily) OR ARB (e.g., losartan 50mg daily) 1, 5
• Alternative: Low-dose calcium channel blocker (amlodipine 5mg daily) 1

For Black Patients:

• Start low-dose ARB PLUS dihydropyridine calcium channel blocker (e.g., amlodipine 5mg) 1
• Alternative: Calcium channel blocker plus thiazide-like diuretic 1

Step 2: Increase to Full Dose (If BP Still Elevated After 2-4 Weeks)

• Uptitrate ACE inhibitor/ARB to maximum dose (e.g., lisinopril 40mg, losartan 100mg) 1
• OR uptitrate calcium channel blocker to full dose (amlodipine 10mg) 1

Step 3: Add Second Agent (Dual Therapy)

For Non-Black Patients:

• Add dihydropyridine calcium channel blocker (amlodipine 5-10mg) to ACE inhibitor/ARB 1, 6
• Alternative: Add thiazide-like diuretic (chlorthalidone 12.5-25mg or hydrochlorothiazide 25mg) 1, 6

For Black Patients:

• If started on CCB + diuretic, add ARB or ACE inhibitor 1
• If started on ARB + CCB, add thiazide-like diuretic 1

Step 4: Triple Therapy (If BP Still Uncontrolled)

• Combine ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic at full doses 1, 6
• This represents guideline-recommended triple therapy with complementary mechanisms 6

Step 5: Resistant Hypertension (Fourth Agent)

• Add spironolactone 25-50mg daily as preferred fourth-line agent 1, 6
• Alternatives if spironolactone not tolerated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Blood Pressure Targets

• Initial goal: Reduce BP by at least 20/10 mmHg 1, 5
• Primary target: <140/90 mmHg for most patients 1, 2
• Optimal target: <130/80 mmHg for higher-risk patients (diabetes, CKD, CVD) 1, 6
• Timeline: Achieve target within 3 months of starting or modifying therapy 1, 6

Monitoring Schedule

• Week 2-4: Reassess BP after initiating or changing medication 1, 6
• Check labs: Serum potassium and creatinine 2-4 weeks after starting ACE inhibitor/ARB or diuretic 6
• Home BP monitoring: Use to confirm control and improve adherence 5
• Follow-up visits: Every 2-4 weeks until target achieved, then every 3-6 months 1

Critical Pitfalls to Avoid

• Don't delay treatment in high-risk patients (CVD, CKD, diabetes, organ damage, age 50-80)—start medication immediately 1, 5
• Don't combine ACE inhibitor with ARB—increases adverse events without benefit 6
• Don't add beta-blocker as routine second or third agent unless compelling indication (angina, post-MI, heart failure, rate control needed) 6
• Don't assume treatment failure without first confirming medication adherence and ruling out secondary hypertension 6
• Don't use non-dihydropyridine CCBs (diltiazem, verapamil) if heart failure present 6

When to Refer to Specialist

• BP remains ≥160/100 mmHg despite 4-drug therapy at optimal doses 1, 6
• Suspected secondary hypertension (young age, sudden onset, resistant hypertension) 5
• Multiple drug intolerances 6
• Concerning features requiring specialized evaluation 1

Medication-Specific Monitoring

ACE Inhibitors/ARBs:

• Monitor for cough (ACE inhibitors), hyperkalemia, acute kidney injury 6
• Check potassium and creatinine 1-4 weeks after initiation or dose increase 6

Thiazide Diuretics:

• Monitor for hypokalemia, hyperuricemia, glucose intolerance 6
• Chlorthalidone preferred over hydrochlorothiazide due to longer duration of action 6, 7

Calcium Channel Blockers:

• Monitor for peripheral edema (may be attenuated by adding ACE inhibitor/ARB) 6