What are the options for treating hypertension?

Treatment Options for Hypertension

For most adults with hypertension, treatment should begin with lifestyle modifications and, when pharmacological therapy is indicated, start with an ACE inhibitor or ARB, progressing to combination therapy with a calcium channel blocker and/or thiazide diuretic to achieve a target blood pressure of <130/80 mmHg. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, confirm the diagnosis using proper measurement techniques and monitoring 1, 2:

• Use validated automated upper arm cuff devices with appropriate cuff size, measuring both arms at first visit and using the arm with higher readings subsequently 1
• Hypertension is diagnosed when office BP is consistently ≥140/90 mmHg, confirmed with home monitoring (<135/85 mmHg) or 24-hour ambulatory monitoring (<130/80 mmHg) 1, 2
• Obtain multiple measurements across different times to assess BP patterns and variability 3

Lifestyle Modifications (First-Line for All Patients)

Lifestyle changes should be implemented initially or concurrently with pharmacological treatment 4, 5:

• Weight reduction to achieve ideal body weight through reduced calorie intake; a 10 kg weight loss can reduce systolic BP by 6 mmHg and diastolic by 4.6 mmHg 3, 2
• Sodium restriction to <2,300 mg/day (can lower systolic BP by 9 mmHg and diastolic by 8 mmHg in resistant cases) 3, 5
• DASH diet emphasizing fruits, vegetables, low-fat dairy, and reduced saturated fat with increased potassium intake (8-10 servings of fruits and vegetables daily) 3, 2
• Regular aerobic exercise at least 150 minutes per week of moderate intensity 2, 5
• Alcohol moderation to ≤2 standard drinks/day for men and ≤1 for women (or <14 units/week for men, <8 for women) 1, 2

Pharmacological Treatment Algorithm

When to Start Medications

• Immediately in high-risk patients (with cardiovascular disease, chronic kidney disease, diabetes, organ damage, or aged 50-80 years) when BP ≥140/90 mmHg 1, 2
• After 3-6 months of lifestyle intervention in low-moderate risk patients with persistent BP ≥140/90 mmHg 1, 2

First-Line Medication Choices

For non-black patients 1, 2:

• Start with low-dose ACE inhibitor (e.g., lisinopril) or ARB (e.g., losartan) 1, 6, 7
• These medications lower BP and reduce cardiovascular events, stroke, and mortality 6, 7

For black patients 1, 2:

• Start with low-dose ARB + dihydropyridine calcium channel blocker (CCB), OR
• CCB + thiazide/thiazide-like diuretic 1

Medication Escalation Sequence

Progress through the following steps to achieve target BP 2, 5:

1. Step 1: Low-dose ACE inhibitor or ARB 2
2. Step 2: Increase to full dose 2
3. Step 3: Add calcium channel blocker (e.g., amlodipine) or thiazide-like diuretic (e.g., chlorthalidone) 2, 5
4. Step 4: Add spironolactone 25 mg/day for resistant hypertension 1, 2
5. Step 5: Consider alternatives if spironolactone not tolerated: eplerenone, doxazosin, clonidine, or beta-blocker 2

Combination therapy is preferred over monotherapy in high-risk patients as it provides more stable 24-hour BP control 3

Medication Classes and Side Effects

The following antihypertensive classes are effective 4:

• Thiazide-type diuretics: electrolyte disturbances, GI discomfort, rashes, sexual dysfunction in men, photosensitivity, orthostatic hypotension 4
• ACE inhibitors: cough, hyperkalemia 4
• ARBs: dizziness, cough, hyperkalemia 4
• Calcium channel blockers: dizziness, headache, edema, constipation 4
• Beta-blockers: fatigue, sexual dysfunction 4

Blood Pressure Targets

Target BP varies by patient characteristics 1, 2:

• Most adults: <130/80 mmHg 1, 2
• Adults ≥60 years: <150/90 mmHg (moderate-quality evidence supports this less aggressive target to reduce mortality, stroke, and cardiac events) 4
• Elderly with frailty: <140/80 mmHg, individualized based on tolerability 1, 2
• History of stroke/TIA: <140/80 mmHg (or <130/80 mmHg if younger) to reduce recurrent stroke risk 4, 1
• Coronary artery disease: <130/80 mmHg (<140/80 in elderly) 1
• Heart failure: <130/80 mmHg but >120/70 mmHg 1
• Diabetes: <130/80 mmHg 1
• Chronic kidney disease: depends on proteinuria level 1

Monitoring and Follow-Up

• Aim to achieve target BP within 3 months 1, 2
• Schedule monthly visits until BP target is achieved 2
• Use home BP monitoring to guide medication adjustments and improve adherence 3, 2
• Check for orthostatic hypotension in elderly patients and those with diabetes 3, 2
• Screen for medication non-adherence (affects 10-80% of patients) and simplify regimens when possible 2

Special Considerations

• Resistant hypertension (BP uncontrolled on 3 medications including a diuretic): add spironolactone as fourth-line agent 1, 2
• Secondary hypertension: screen for obstructive sleep apnea, pheochromocytoma, renal artery stenosis, and primary aldosteronism in young patients or those with resistant hypertension 3
• Interfering substances: identify and eliminate NSAIDs, decongestants, stimulants, excessive alcohol, and licorice 3
• Generic medications: prescribe generic drugs where available to reduce cost 4
• Once-daily dosing: use long-acting agents to minimize fluctuations and improve adherence 3