What is the recommended treatment approach for a patient with hypertension, considering lifestyle modifications and medication options?

Hypertension Treatment Approach

For most patients with hypertension, treatment should begin with lifestyle modifications, and pharmacologic therapy should be initiated with a thiazide or thiazide-like diuretic, ACE inhibitor or ARB, or calcium channel blocker, titrated to achieve a blood pressure target of <130/80 mm Hg for adults under 65 years and <130 mm Hg systolic for those 65 years and older. 1, 2, 3

Initial Assessment and Diagnosis Confirmation

• Confirm the diagnosis using home blood pressure monitoring (≥135/85 mm Hg) or 24-hour ambulatory monitoring (≥130/80 mm Hg) in addition to office readings, as clinic measurements may overestimate true blood pressure 2, 4
• Calculate body mass index and assess alcohol consumption in all patients, and evaluate sodium intake and stress levels in hypertensive patients 1
• Screen for secondary causes of hypertension if blood pressure is refractory (≥5 drugs including a diuretic with BP above goal), if there is unprovoked hypokalemia, or if diastolic hypertension develops in patients ≥65 years 1

Lifestyle Modifications (First-Line for All Patients)

All patients with elevated blood pressure or hypertension should implement lifestyle changes, which can reduce blood pressure by 10-20 mm Hg and may eliminate the need for medications in some cases. 1, 3

• Sodium restriction: Reduce intake to <1500 mg/day, or at minimum achieve an absolute reduction of 1000 mg/day 1
• Weight management: Achieve and maintain ideal body weight, or lose at least 1 kg if overweight (target BMI 20-25 kg/m²) 1, 2
• Dietary potassium: Increase intake to 3500-5000 mg/day through diet 1
• Physical activity: Engage in aerobic or dynamic resistance exercise for 90-150 minutes per week, or isometric resistance training 3 sessions per week 1
• Alcohol moderation: Limit to ≤2 drinks per day for men and ≤1 per day for women (maximum 14/week for men, 9/week for women) 1, 5
• DASH diet: Follow a dietary pattern rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced saturated and total fat 1

The blood pressure-lowering effects of these interventions are partially additive and enhance the efficacy of pharmacologic therapy 3, 6

Indications for Pharmacologic Therapy

Initiate antihypertensive medication based on blood pressure level and cardiovascular disease risk, not solely on the blood pressure threshold of 130/80 mm Hg. 1, 3

• Stage 1 hypertension (130-139/80-89 mm Hg): Start medication if the patient has established cardiovascular disease, diabetes, chronic kidney disease, or high atherosclerotic CVD risk 1, 3
• Stage 2 hypertension (≥140/90 mm Hg): Initiate pharmacologic therapy in all patients 1, 3
• Elevated BP (120-129/<80 mm Hg): Lifestyle modifications only; recheck every 3-6 months 1

First-Line Medication Options

The three first-line drug classes are thiazide or thiazide-like diuretics, ACE inhibitors or ARBs, and calcium channel blockers. 1, 2, 3

Selection Based on Patient Characteristics:

• Black patients: Prefer a calcium channel blocker or thiazide diuretic over ACE inhibitor/ARB as initial monotherapy 2, 7
• Non-Black patients: Any of the three first-line classes is appropriate 2, 3
• Patients with diabetes and albuminuria: Prefer ACE inhibitor or ARB 1
• Patients with chronic kidney disease: Prefer ACE inhibitor or ARB 1, 2
• Patients with heart failure: Prefer ACE inhibitor or ARB 1, 2
• Patients with atrial fibrillation: Prefer ARB to reduce recurrence 1
• Patients with coronary artery disease: ACE inhibitor or ARB combined with calcium channel blocker is beneficial 2

Specific Drug Recommendations:

• Thiazide-like diuretics: Chlorthalidone 12.5-25 mg daily is preferred over hydrochlorothiazide due to longer duration of action and proven cardiovascular disease reduction 2, 8
• ACE inhibitors: Lisinopril 10-40 mg daily or enalapril 7, 3
• ARBs: Candesartan, olmesartan, or valsartan 2, 3
• Calcium channel blockers: Amlodipine 5-10 mg daily 2, 3

Stepwise Medication Intensification Algorithm

If blood pressure remains uncontrolled on monotherapy, follow this sequential approach:

Step 1: Optimize Initial Agent

• Titrate the first medication to maximum tolerated dose before adding a second agent 2, 4
• Allow 2-4 weeks for full effect of dose adjustments 4

Step 2: Add Second Agent

• For non-Black patients: If starting with ACE inhibitor/ARB, add calcium channel blocker; if starting with calcium channel blocker, add ACE inhibitor/ARB 2, 4
• For Black patients: Combine calcium channel blocker with thiazide diuretic, as this may be more effective than calcium channel blocker plus ACE inhibitor/ARB 2
• The combination of ACE inhibitor/ARB with calcium channel blocker provides complementary mechanisms and superior blood pressure control compared to either agent alone 2

Step 3: Add Third Agent (Triple Therapy)

• Add a thiazide or thiazide-like diuretic to complete the guideline-recommended triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 2, 3
• This combination targets different mechanisms: volume reduction, vasodilation, and renin-angiotensin system blockade 2
• Monitor serum potassium and creatinine 2-4 weeks after initiating diuretic therapy 2

Step 4: Resistant Hypertension (Fourth Agent)

• Add spironolactone 25-50 mg daily as the preferred fourth-line agent if blood pressure remains uncontrolled (≥140/90 mm Hg) despite optimized triple therapy 2, 4
• Monitor potassium closely when adding spironolactone to an ACE inhibitor/ARB, as hyperkalemia risk is significant 2
• Alternative fourth-line agents if spironolactone is contraindicated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 2

Blood Pressure Targets

• Adults <65 years: <130/80 mm Hg 1, 2, 3
• Adults ≥65 years: <130 mm Hg systolic 1, 2
• Patients with diabetes or chronic kidney disease: <130/80 mm Hg 1, 8
• Aim to achieve target blood pressure within 3 months of initiating or modifying therapy 2, 4

Monitoring Schedule

• Patients initiating drug therapy: Follow approximately monthly for dose titration until blood pressure is controlled 1
• After medication adjustment: Reassess within 2-4 weeks 2, 4
• Controlled hypertension: Monitor every 3-6 months 1
• Normal blood pressure or white coat hypertension: Recheck annually 1

Critical Pitfalls to Avoid

• Never combine an ACE inhibitor with an ARB, as this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit 2, 4
• Do not add a third drug class before maximizing doses of the current two-drug regimen, as this violates guideline-recommended stepwise approaches and may expose patients to unnecessary polypharmacy 2
• Always verify medication adherence before adding additional agents, as non-adherence is the most common cause of apparent treatment resistance 2, 4
• Do not add a beta-blocker as a third agent unless there are compelling indications such as angina, post-myocardial infarction, heart failure with reduced ejection fraction, or need for heart rate control 2
• Monitor for peripheral edema with calcium channel blockers, which may be attenuated by adding an ACE inhibitor or ARB 2
• Do not withhold appropriate treatment intensification solely based on age; individualize blood pressure targets for elderly patients based on frailty 2

When to Refer to Specialist

• Blood pressure remains uncontrolled (≥160/100 mm Hg) despite four-drug therapy at optimal doses 2, 4
• Suspected secondary hypertension (primary aldosteronism, renal artery stenosis, obstructive sleep apnea, pheochromocytoma) 1, 2
• Multiple drug intolerances 2
• Refractory hypertension (taking ≥5 drugs including a diuretic with BP above goal) 1