What is the approach to managing a patient with hypertension?

Approach to a Patient with High Blood Pressure Reading

When encountering a patient with an elevated blood pressure reading, do not diagnose or treat based on a single measurement—confirm the diagnosis with repeated measurements over time or out-of-office monitoring before initiating therapy, unless the patient presents with malignant hypertension or hypertensive emergency. 1

Initial Assessment and Confirmation

Verify the Blood Pressure Reading

• Ensure proper measurement technique: Patient seated with back supported, arm at heart level, appropriate cuff size, after 3-5 minutes of rest, with at least two measurements per visit 2
• Single office readings overestimate true BP by 10-15 mmHg and should never be used alone for diagnosis 2
• Confirm with out-of-office measurements using either home blood pressure monitoring (HBPM) or 24-hour ambulatory blood pressure monitoring (ABPM) 1

Classification Based on Confirmed Readings

Once confirmed with repeated or out-of-office measurements 1:

• Normal BP: Office SBP <120 mmHg AND DBP <70 mmHg 1
• Elevated BP: Office SBP 120-139 mmHg and/or DBP 70-89 mmHg 1
• Hypertension: Office SBP ≥140 mmHg and/or DBP ≥90 mmHg 1

Exception: Immediate Treatment Required

For malignant phase hypertension (typically DBP >110 mmHg with target organ damage), initiate antihypertensive drugs immediately without prolonged observation 1

Risk Stratification

Assess Cardiovascular Risk

• Calculate 10-year cardiovascular disease risk using SCORE2 (for adults <70 years) or SCORE2-OP (for adults ≥70 years) 1
• Identify target organ damage: Order electrocardiogram (mandatory but often omitted in 89% of cases) 3, assess for left ventricular hypertrophy, retinopathy, proteinuria, or elevated creatinine 1
• Document additional risk factors: diabetes, dyslipidemia, smoking, family history of premature cardiovascular disease, male sex, advanced age 1

Screen for Secondary Causes

In patients with resistant hypertension or clinical clues, evaluate for 2:

• Primary aldosteronism (present in 15-20% of resistant hypertension) 2
• Obstructive sleep apnea (present in ≥80% of resistant hypertension) 2
• Renal artery stenosis (especially with atherosclerotic disease or fibromuscular dysplasia) 2
• Medication interference: NSAIDs, decongestants, stimulants, oral contraceptives, excessive alcohol 2

Treatment Initiation Strategy

For Elevated BP (120-139/70-89 mmHg)

• Low/medium CVD risk (<10% over 10 years): Initiate lifestyle modifications alone for 3 months 1
• High CVD risk (≥10% over 10 years): After 3 months of lifestyle intervention, if BP remains ≥130/80 mmHg, add pharmacological treatment 1

For Hypertension (≥140/90 mmHg)

Initiate both lifestyle modifications and pharmacological treatment promptly, regardless of CVD risk 1

Pharmacological Treatment

First-Line Medications

Use ACE inhibitors, ARBs, dihydropyridine calcium channel blockers (CCBs), or thiazide/thiazide-like diuretics (chlorthalidone, indapamide)—these have demonstrated the most effective reduction in BP and cardiovascular events 1, 4

Initial Regimen

For most patients with confirmed hypertension (BP ≥140/90 mmHg), start with combination therapy using two drugs 1:

• Preferred combination: RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB OR RAS blocker + thiazide-like diuretic 1
• Use fixed-dose single-pill combinations to improve adherence (up to 25% of patients don't fill initial prescriptions and only 20% maintain adequate adherence) 2

Exceptions to starting with combination therapy 1:

• Patients aged ≥85 years
• Symptomatic orthostatic hypotension
• Moderate-to-severe frailty
• Elevated BP (not hypertension) with specific indication for treatment

Dose Titration

• Titrate to maximum tolerated doses within 3 months to achieve target BP and retain patient confidence 1
• If BP not controlled with two drugs, escalate to three-drug combination: RAS blocker + dihydropyridine CCB + thiazide-like diuretic, preferably as single-pill combination 1

Fourth-Line Agent for Resistant Hypertension

Add spironolactone 25-50 mg daily as the preferred fourth agent (provides superior BP reduction of 8-10 mmHg systolic compared to other options) 2

• Monitor serum potassium and creatinine 2-4 weeks after initiation due to hyperkalemia risk with concurrent ACE inhibitor/ARB 2

Beta-Blockers

Reserve beta-blockers for compelling indications: angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control 1

Medication Timing

Instruct patients to take medications at the most convenient time of day to establish a habitual pattern and improve adherence—current evidence shows no benefit of specific diurnal timing on cardiovascular outcomes 1

Lifestyle Modifications (Essential for All Patients)

Dietary Interventions

• Adopt Mediterranean or DASH diet to reduce BP and cardiovascular risk 1
• Restrict sodium to <2,000 mg/day (can lower BP by 5-6 mmHg) 2
• Increase potassium intake through diet 4
• Limit free sugar to maximum 10% of energy intake and discourage sugar-sweetened beverages 1

Weight Management

Achieve and maintain BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women)—weight loss of 5-10% body weight provides approximately 1 mmHg reduction per kg lost 1, 2

Physical Activity

Engage in moderate-intensity aerobic exercise for at least 30 minutes on at least 3 days per week, complemented with low- or moderate-intensity resistance training 2-3 times per week 1, 5

• Regular exercise provides overall 5 mmHg BP decrease and post-exercise hypotension lasting up to 24 hours 5

Alcohol and Tobacco

• Limit alcohol to <100 g/week of pure alcohol (preferably avoid completely for best health outcomes) 1
• Stop tobacco smoking immediately and refer to cessation programs 1

Blood Pressure Targets

General Target

Treat systolic BP to 120-129 mmHg in most adults, provided treatment is well tolerated 1

• Target diastolic BP: 70-79 mmHg 1
• This represents the optimal target under research conditions, though achieving <130/80 mmHg is acceptable in routine practice 1

When Target Cannot Be Achieved

If achieving 120-129/70-79 mmHg is not possible or poorly tolerated, target BP "as low as reasonably achievable" (ALARA principle) 1

Special Populations

• Adults ≥65 years: Target SBP <130 mmHg 4
• Patients with diabetes or chronic kidney disease: Target <130/80 mmHg 6
• Patients with history of stroke/TIA: Target systolic BP 120-129 mmHg to reduce cardiovascular outcomes 1

Follow-Up Strategy

Monitoring Schedule

• Schedule visits every 2-4 weeks until BP target is achieved, then extend intervals 2
• For diastolic BP 100-109 mmHg without target organ damage: Observe initially weekly, then monthly, while continuing non-pharmacological treatment 1
• Encourage home BP monitoring twice daily to assess treatment effectiveness 1

Team-Based Care

Implement multidisciplinary care involving physicians, pharmacists, nurses, and health coaches—this approach improves BP control rates from 44% to 80% 2

Critical Pitfalls to Avoid

Therapeutic Inertia

The most common management error is failing to intensify treatment when BP remains uncontrolled at consecutive visits—do not accept persistent uncontrolled BP 2

Inadequate Diuretic Therapy

Replace hydrochlorothiazide with chlorthalidone or indapamide for superior 24-hour BP control and greater effectiveness in resistant hypertension 2

• Hydrochlorothiazide is less potent than thiazide-like diuretics 2

Assuming Medication Adherence

Assess adherence objectively through pharmacy refill records, pill counts, or electronic monitoring—non-adherence accounts for up to 50% of apparent treatment failure 2

• Never rely solely on patient self-report 2

Staging on Single Measurement

Do not stage hypertension based on a single BP recording (occurs incorrectly in 85% of cases)—repeated measurements over time more precisely predict risk 1, 3

Incomplete Cardiovascular Risk Assessment

Order mandatory laboratory tests (electrocardiogram, lipid panel, creatinine, urinalysis)—these are frequently omitted in clinical practice 3

Underdosing or Monotherapy Persistence

After 18 months, 40% of patients remain on monotherapy despite inadequate control—escalate therapy appropriately 3

• Only 33% of patients achieve target BP with current practice patterns 3

Contraindicated Drug Combinations

Never combine two RAS blockers (ACE inhibitor + ARB)—this is not recommended 1

Lifelong Management

Maintain BP-lowering drug treatment lifelong, even beyond age 85 years, if well tolerated 1

• Stopping treatment in very old people requires close monitoring to determine effects 1