What are the management steps for patients with elevated blood pressure (BP) or hypertension?

Management of Elevated Blood Pressure and Hypertension

For patients with elevated BP or Stage 1 hypertension without high cardiovascular risk, initiate lifestyle modifications and reassess BP in 3-6 months; for Stage 2 hypertension or Stage 1 with high cardiovascular risk (≥10% 10-year ASCVD risk), start combination pharmacotherapy immediately alongside lifestyle changes. 1

Initial Blood Pressure Classification and Risk Stratification

BP Categories and Immediate Actions

• Elevated BP (120-129/<80 mmHg): Implement lifestyle counseling and repeat BP measurement in 6 months 1
• Stage 1 Hypertension (130-139/80-89 mmHg):
  • If 10-year ASCVD risk <10%: Lifestyle modifications with BP reassessment in 3-6 months 1
  • If 10-year ASCVD risk ≥10%: Initiate both lifestyle modifications AND antihypertensive medication, with follow-up in 1 month 1
• Stage 2 Hypertension (≥140/90 mmHg): Start combination therapy (lifestyle + 2 antihypertensive agents from different classes) with evaluation by primary care within 1 month 1
• Hypertensive Crisis (SBP ≥180 or DBP ≥110 mmHg): Prompt evaluation and immediate antihypertensive treatment within 1 week maximum 1

Critical Pitfall: White Coat Hypertension

• Confirm diagnosis with home BP monitoring (≥135/85 mmHg confirms hypertension) or 24-hour ambulatory monitoring (≥130/80 mmHg confirms hypertension) before initiating pharmacotherapy in patients with low cardiovascular risk 1

Lifestyle Modifications (Foundation for All Patients)

Evidence-Based Interventions (Class I Recommendations)

• Weight loss: Target BMI 20-25 kg/m² for overweight/obese patients; provides 5-20 mmHg reduction per 10 kg weight loss 1, 2
• DASH diet: Emphasizes fruits, vegetables, low-fat dairy, reduced saturated fat and cholesterol; achieves 8-14 mmHg SBP reduction 1, 3, 4
• Sodium restriction: Limit intake to <2 g/day; produces 2-8 mmHg SBP reduction 1, 2
• Potassium supplementation: Preferably through dietary modification (unless contraindicated by CKD or potassium-sparing medications); reduces BP by 4-5 mmHg 1, 4
• Physical activity: Structured aerobic exercise ≥150 minutes/week plus resistance training 2-3 times/week; lowers BP by 4-9 mmHg 1, 2
• Alcohol moderation: Limit to ≤2 standard drinks/day for men, ≤1 for women; reduces BP by 2-4 mmHg 1, 2

Implementation Strategy

• These interventions have partially additive effects—combining multiple modifications can achieve 10-20 mmHg total reduction 1, 2
• Lifestyle changes enhance antihypertensive medication efficacy and should continue even when drugs are initiated 3, 2
• For patients with CKD, involve registered dietitian for medical nutrition therapy to modify DASH diet appropriately 1

Pharmacological Management Algorithm

Initial Drug Selection

• First-line agents (choose based on patient characteristics): 2
  • Thiazide/thiazide-like diuretic (hydrochlorothiazide 12.5-25 mg or chlorthalidone 12.5-25 mg daily)
  • ACE inhibitor (e.g., lisinopril 10-40 mg daily) or ARB (e.g., losartan 50-100 mg daily)
  • Calcium channel blocker (e.g., amlodipine 5-10 mg daily)

Combination Therapy Progression

• Stage 2 hypertension: Start with 2 agents from different classes immediately 1
• Uncontrolled on monotherapy: Add second agent rather than maximizing first drug dose 5
• Standard triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 5
• Resistant hypertension (uncontrolled on 3 drugs): Add spironolactone 25-50 mg daily as fourth agent 5

Race-Specific Considerations

• Black patients: Calcium channel blocker + thiazide diuretic combination may be more effective than CCB + ACE inhibitor/ARB 5
• Non-Black patients: Standard sequence is ACE inhibitor/ARB → add CCB → add thiazide diuretic 5

Critical Contraindications

• Never combine ACE inhibitor with ARB: Increases adverse events (hyperkalemia, acute kidney injury) without cardiovascular benefit 5
• Avoid non-dihydropyridine CCBs (diltiazem, verapamil) in heart failure patients 5

Follow-Up and Monitoring Schedule

BP Reassessment Timing

• Normal BP: Annual screening 1
• Elevated BP: 6 months 1
• Stage 1 hypertension (low risk): 3-6 months 1
• Stage 1 hypertension (high risk) or Stage 2: 1 month after treatment initiation 1
• After medication adjustment: 2-4 weeks 5

Treatment Targets

• Most adults <65 years: SBP/DBP <130/80 mmHg 2
• Adults ≥65 years: SBP <130 mmHg 2
• Minimum acceptable target: <140/90 mmHg 1, 2
• Goal timeline: Achieve target BP within 3 months of treatment initiation or modification 5

Laboratory Monitoring

• Baseline: Serum creatinine, eGFR, urine albumin-to-creatinine ratio, 12-lead ECG 6
• After starting ACE inhibitor/ARB or diuretic: Check potassium and creatinine in 2-4 weeks 5
• Ongoing: Monitor for hyperkalemia (especially with ACE inhibitor/ARB), hypokalemia (with thiazides), and changes in renal function 5

Persistent/Resistant Hypertension Management

Before Adding Fourth Agent

• Confirm medication adherence: Non-adherence is the most common cause of apparent treatment resistance 1
• Verify true hypertension: Use home or ambulatory BP monitoring to exclude white coat effect 1
• Screen for secondary causes: 5
  • Primary aldosteronism
  • Renal artery stenosis
  • Obstructive sleep apnea
  • Medication interference (NSAIDs, decongestants, oral contraceptives)

Specialty Referral Indications

• BP ≥160/100 mmHg despite 4-drug therapy at optimal doses 5
• Suspected secondary hypertension 5
• Multiple drug intolerances 5
• Age <30 years with Stage 2 hypertension (suggests secondary cause) 5

Treatment-Resistant Hypertension Strategy

• Optimize existing medications before adding new agents 5
• Use complementary mechanisms: thiazide diuretic + ACE inhibitor/ARB + aldosterone antagonist is particularly effective 1
• Reinforce sodium restriction to <2 g/day—critical for treatment resistance 1
• Consider spironolactone 25-50 mg as preferred fourth agent (provides additional 20-25/10-12 mmHg reduction) 5