What is the approach to managing a new case of hypertension?

Management of New Hypertension

Begin pharmacological therapy with a thiazide or thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide), ACE inhibitor/ARB, or calcium channel blocker as first-line monotherapy, titrating to target BP <130/80 mmHg in most adults under 65 years, or SBP <130 mmHg in adults ≥65 years. 1, 2, 3, 4

Initial Assessment and Risk Stratification

Before initiating treatment, establish the patient's cardiovascular risk profile to determine BP targets and treatment intensity 1, 4:

• Measure BP accurately using standardized technique with appropriate cuff size to avoid spurious readings 1, 5
• Screen for target organ damage: obtain echocardiogram for left ventricular hypertrophy, fundoscopy for retinopathy, urinary albumin-to-creatinine ratio for kidney damage 1, 5
• Calculate 10-year atherosclerotic CVD risk using Framingham or similar validated tool 1, 4
• Identify compelling indications for specific drug classes: post-MI (beta-blockers), heart failure (ACE inhibitors/ARBs), diabetes, chronic kidney disease 1, 3
• Rule out secondary causes if resistant to therapy or clinical features suggest: renal artery stenosis, primary aldosteronism, pheochromocytoma, obstructive sleep apnea 1

Blood Pressure Targets

Target BP varies by age and comorbidities 1, 4:

• Adults <65 years: <130/80 mmHg 4
• Adults ≥65 years: SBP <130 mmHg 4
• High-risk patients (diabetes, chronic kidney disease, CAD, 10-year Framingham risk ≥10%): <130/80 mmHg 1
• Caution in elderly with wide pulse pressure: avoid DBP <60 mmHg, which may compromise coronary perfusion 1

Lifestyle Modifications (Mandatory for All Patients)

Lifestyle changes are first-line therapy and enhance medication efficacy 4, 5, 6:

• Sodium restriction: <2 grams per day 7, 4
• Weight loss: if overweight/obese, even modest reduction (5-10 kg) significantly lowers BP 4, 5
• DASH diet: emphasize fruits, vegetables, whole grains, low-fat dairy, high potassium intake 4, 5
• Physical activity: moderate-intensity aerobic exercise 30 minutes daily, at least 5 days per week (brisk walking is ideal) 4, 6
• Alcohol limitation: ≤1 drink per day 7, 4
• Smoking cessation: mandatory for cardiovascular risk reduction 1, 5

These interventions produce additive BP reductions of 5-10 mmHg and may prevent progression to requiring medication 4, 6.

Pharmacological Therapy: First-Line Drug Selection

Choose from four equally effective first-line classes 1, 2, 3, 4, 5:

Thiazide/Thiazide-Like Diuretics

• Chlorthalidone or indapamide preferred over hydrochlorothiazide due to longer half-life and superior outcomes data 1, 8
• Start low dose (chlorthalidone 12.5-25 mg daily) 1, 8
• Contraindications: gout (compelling), metabolic syndrome, glucose intolerance, pregnancy (possible) 1
• Monitor potassium and creatinine 1

ACE Inhibitors or ARBs

• Examples: lisinopril 10-40 mg daily, enalapril, candesartan 3, 4
• Preferred in: diabetes, chronic kidney disease, heart failure, post-MI 1, 3
• Compelling contraindications: pregnancy, angioedema history, hyperkalemia, bilateral renal artery stenosis 1
• Monitor potassium and creatinine, especially if combined with diuretics 1

Calcium Channel Blockers

• Dihydropyridines (amlodipine 5-10 mg daily) for hypertension 2, 4
• Non-dihydropyridines (diltiazem, verapamil) if concurrent angina or tachyarrhythmias 1
• Contraindications: verapamil/diltiazem in AV block grade 2-3 or heart failure 1
• Well-tolerated with minimal dose-dependent side effects 1, 2

Beta-Blockers

• Not first-line unless compelling indication: post-MI, angina, heart failure 1
• Contraindications: asthma (compelling), peripheral artery disease, metabolic syndrome, COPD (possible) 1

Treatment Algorithm

Step 1: Monotherapy Initiation

• Start with low-dose monotherapy from one first-line class 1, 4
• Titrate to full dose if BP not controlled after 2-4 weeks 1
• If no response or intolerable side effects: switch to different class (sequential monotherapy) 1
• Monotherapy achieves target BP in only 20-30% of patients, except grade 1 hypertension 1

Step 2: Combination Therapy (Most Patients Require This)

If BP >20/10 mmHg above goal, start with two-drug combination immediately 1, 4:

• Preferred combinations (synergistic and complementary mechanisms) 1, 4:
  • ACE inhibitor/ARB + thiazide diuretic
  • ACE inhibitor/ARB + calcium channel blocker
  • Calcium channel blocker + thiazide diuretic
• Use low doses of both agents initially to minimize side effects 1
• Advantage: 90% of patients require ≥2 drugs to reach target; starting combination avoids frustrating sequential monotherapy failures 1

Step 3: Triple Therapy

If BP remains uncontrolled on two drugs 1:

• Add third agent from remaining first-line class 1
• Optimize regimen: ensure adequate doses, correct timing, assess adherence 1
• Substitute chlorthalidone or indapamide if hydrochlorothiazide was used 1

Step 4: Resistant Hypertension (BP >140/90 on 3 Drugs Including Diuretic)

Add mineralocorticoid receptor antagonist (MRA) 1:

• Spironolactone 25-50 mg daily is most effective fourth-line agent per PATHWAY-2 trial 1
• Alternative: amiloride if spironolactone not tolerated 1
• Monitor potassium closely, especially with reduced GFR or concurrent ACE inhibitor/ARB 1
• Consider patiromer (potassium binder) to enable MRA use in CKD patients 1

Step 5: Refractory Cases

• Screen for secondary hypertension: primary aldosteronism (most common), renal artery stenosis, pheochromocytoma, obstructive sleep apnea 1
• Assess adherence: poor compliance is the most common cause of apparent resistance 1
• Confirm with ambulatory BP monitoring: exclude white coat effect 1
• Refer to hypertension specialist for consideration of additional agents or device-based therapies 1, 7

Monitoring and Follow-Up

• Initial phase: visit every 2-4 weeks until BP controlled 1
• Once controlled: every 3-6 months 1
• Home BP monitoring: strongly encouraged to assess out-of-office control and improve adherence 1, 5
• Reassess target organ damage: repeat echocardiography, urinary albumin every 6-12 months until regression documented 1, 7

Critical Pitfalls to Avoid

• Therapeutic inertia: failure to initiate or intensify therapy is a major barrier; 83% of visits with elevated BP do not result in treatment changes 1
• Inadequate dosing: titrate to full doses before adding agents 1
• Using hydrochlorothiazide instead of chlorthalidone: inferior outcomes and shorter duration of action 1, 8
• Ignoring adherence: simplify regimens, address cost barriers, use combination pills when possible 1
• Rapid BP lowering in chronic hypertension: lower gradually over weeks to avoid ischemic complications, especially in elderly 1
• Missing secondary causes: screen appropriately in resistant cases or young patients 1

Expected Outcomes

• Each 10 mmHg SBP reduction decreases CVD events by 20-30%, stroke by 14%, and all-cause mortality by 7% 4, 6
• Lifestyle modifications alone can reduce BP by 5-10 mmHg 4, 6
• Most patients require ≥2 medications to achieve target; accept this reality and initiate combination therapy early 1, 4