What are the initial management recommendations for Hypertension (High Blood Pressure) Stage II?

Hypertension Stage II Management

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

Immediate Pharmacological Therapy

Start with two-drug combination therapy from different classes:

• Preferred initial combinations: 1, 2

  • ACE inhibitor (e.g., lisinopril 10 mg daily) + thiazide-like diuretic (chlorthalidone 12.5-25 mg daily), OR
  • ACE inhibitor + calcium channel blocker (amlodipine 5 mg daily), OR
  • ARB + calcium channel blocker, OR
  • ARB + thiazide-like diuretic

• Single-pill combinations are preferred to improve medication adherence 1, 2

• Chlorthalidone is preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes data 2, 3

• Target blood pressure: <130/80 mmHg for most adults under 65 years; <130 mmHg systolic for those ≥65 years 1, 2

Special Population Considerations

• Black patients: Use ARB + calcium channel blocker OR calcium channel blocker + thiazide diuretic (ACE inhibitors less effective as monotherapy) 2

• Pregnancy or planning pregnancy: Absolutely avoid ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors due to fetal toxicity risk 2, 4; use methyldopa or calcium channel blockers instead 2

• Bilateral renal artery stenosis: Avoid ACE inhibitors/ARBs due to acute renal failure risk 2

• History of angioedema: Avoid ACE inhibitors 2

• Gout or history of acute gout: Use thiazides cautiously unless on uric acid-lowering therapy 2

Concurrent Lifestyle Modifications

Implement all of the following simultaneously with medications (lifestyle changes enhance drug efficacy and may reduce medication requirements): 1

Dietary Interventions

• DASH diet pattern: Emphasize fruits and vegetables (8-10 servings/day), low-fat dairy products (2-3 servings/day), whole grains, lean proteins 1, 2

• Sodium restriction: Limit to <2,300 mg/day (ideally <1,500 mg/day for greater effect); avoid processed foods and table salt 1, 2, 5

• Potassium supplementation: Increase intake through diet (fruits, vegetables) unless contraindicated by kidney disease 1, 2

Weight and Physical Activity

• Weight loss: Achieve and maintain healthy BMI through caloric restriction if overweight 1, 2, 6

• Regular aerobic exercise: At least 150 minutes of moderate-intensity activity per week 1, 2

Alcohol and Tobacco

• Alcohol moderation: ≤2 standard drinks/day for men, ≤1 drink/day for women (1 standard drink = 12 oz beer, 5 oz wine, or 1.5 oz spirits) 1, 2

• Smoking cessation: Mandatory for all patients 2, 5

Follow-Up and Monitoring

• Recheck BP in 1 month after initiating therapy 1, 2

• Monitor serum creatinine and potassium 7-14 days after starting ACE inhibitors, ARBs, or diuretics 2

• Monitor for hypokalemia with diuretic use 2

• Titrate medications or add third agent if BP goal not achieved within 3 months 1, 2

• If BP remains uncontrolled on two drugs: Add third agent (typically the missing component of ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 2

Critical Pitfalls to Avoid

• Do NOT delay pharmacotherapy for a trial of lifestyle modification alone in Stage 2 hypertension—this increases cardiovascular risk 1, 2

• Do NOT start with monotherapy in Stage 2 hypertension—combination therapy achieves control faster and improves outcomes 1, 2

• Do NOT combine ACE inhibitor + ARB + renin inhibitor—this is potentially harmful and contraindicated 1

• Do NOT use hydrochlorothiazide when chlorthalidone or indapamide are available 2

• Do NOT use beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease, post-MI) 1, 2

Very High BP (≥180/110 mmHg)

For BP ≥180/110 mmHg, initiate treatment within 1 week (or immediately if symptomatic target organ damage present) with evaluation for hypertensive emergency 1