What are the treatment options for stage 2 hypertension?

Treatment of Stage 2 Hypertension

For stage 2 hypertension (BP ≥140/90 mmHg), you must immediately initiate combination therapy with two antihypertensive agents from different drug classes plus lifestyle modifications, with follow-up in 1 month. 1, 2

Immediate Pharmacological Management

Start dual-agent therapy at the first visit—monotherapy is inadequate and delays blood pressure control. 2

Preferred Drug Combinations

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

Specific Drug Options

First-line agents include: 1, 3

• Thiazide-like diuretics: Chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to longer half-life and proven CVD reduction) 1
• ACE inhibitors: Lisinopril 10-40 mg daily, enalapril 5-40 mg daily, or ramipril 2.5-20 mg daily 1, 4
• ARBs: Candesartan 8-32 mg daily, losartan 25-100 mg daily, or irbesartan 150-300 mg daily 1
• Calcium channel blockers: Amlodipine 5-10 mg daily 3

Use single-pill combination formulations when available to improve adherence. 2

Critical Drug Contraindications

• Never combine two RAS blockers (ACE inhibitor + ARB + renin inhibitor)—this is potentially harmful 1, 2
• Avoid ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists in pregnancy or women planning pregnancy 2, 5

Concurrent Lifestyle Modifications (Start Immediately, Not After Medications)

Do not delay medication initiation while attempting lifestyle changes alone—both must start simultaneously in stage 2 hypertension. 1, 2

Weight Loss

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 2
• Expected BP reduction: 5-20 mmHg per 10 kg weight loss 1

DASH Diet

• Emphasize fruits, vegetables, whole grains, low-fat dairy, reduced saturated fat 1
• Expected BP reduction: 11 mmHg systolic in hypertensive patients 1

Sodium Restriction

• Target <1500 mg/day sodium, minimum reduction of 1000 mg/day 1
• Expected BP reduction: 5-6 mmHg systolic 1

Potassium Supplementation

• Target 3500-5000 mg/day through diet 1
• Expected BP reduction: 4-5 mmHg systolic 1

Physical Activity

• 150 minutes/week moderate-intensity aerobic exercise plus resistance training 2-3 times/week 1, 2
• Expected BP reduction: 5-8 mmHg systolic 1

Alcohol Limitation

• Maximum 100 g/week pure alcohol (≤2 drinks/day men, ≤1 drink/day women) 1, 2
• Expected BP reduction: 4 mmHg systolic 1

Blood Pressure Target

Target systolic BP 120-129 mmHg if well tolerated, or at minimum <140/90 mmHg. 2, 5

Follow-Up Schedule

• Recheck BP in 1 month after initiating therapy 1, 2
• Monitor electrolytes and renal function 2-4 weeks after starting ACE inhibitor, ARB, or diuretic 1, 2
• Continue monthly follow-up until BP is controlled 5

Escalation Strategy if Uncontrolled After 1 Month

If BP remains ≥140/90 mmHg on two-drug combination, add a third agent to create triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic. 2, 5

BP control must be achieved within 3 months of initial diagnosis. 2

Fourth-Line Agent for Resistant Hypertension

If uncontrolled on three drugs at optimal doses, add spironolactone 25-50 mg daily as the fourth agent. 5, 6

Special Population Modifications

Patients with Diabetes or Chronic Kidney Disease

• Prioritize ACE inhibitor or ARB as one of the initial two agents 2, 5
• These patients are automatically high ASCVD risk regardless of calculated score 1

Patients with Coronary Artery Disease

• Prioritize ACE inhibitor or ARB as one of the initial agents 2, 5

Patients with Albuminuria (UACR ≥30 mg/g)

• Use ACE inhibitor or ARB to reduce progressive kidney disease risk 5

Patients ≥85 Years or with Moderate-to-Severe Frailty

• Consider single-agent therapy instead of combination therapy 2

Hypertensive Urgency (BP ≥180/110 mmHg)

Promptly treat with immediate antihypertensive medication, careful monitoring, and upward dose adjustment as necessary. 1

Common Pitfalls to Avoid

• Starting monotherapy in stage 2 hypertension—this is inadequate 2
• Delaying medications while attempting lifestyle modifications alone 2
• Using hydrochlorothiazide instead of chlorthalidone—chlorthalidone has superior CVD outcomes 1
• Failing to assess adherence before escalating therapy 7
• Not checking for white-coat hypertension with home BP monitoring 7
• Missing secondary causes (chronic kidney disease, obstructive sleep apnea, hyperaldosteronism) 7, 6
• Overlooking interfering substances, especially NSAIDs 7