What is the recommended management approach for a patient with hypertension?

Hypertension Management

Initial Diagnosis and Confirmation

For patients with elevated office blood pressure readings, confirmation with out-of-office measurements using home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM) is essential before initiating treatment. 1

• Office BP 140-159/90-99 mmHg requires confirmation via HBPM (≥135/85 mmHg) or ABPM (daytime mean ≥130/80 mmHg) 1
• Office BP ≥160/100 mmHg should be confirmed as soon as possible (within 1 month), preferably by HBPM or ABPM 1
• Office BP ≥180/110 mmHg requires immediate exclusion of hypertensive emergency 1

Essential Initial Workup

All patients with confirmed hypertension require baseline laboratory assessment including serum creatinine, eGFR, urine albumin-to-creatinine ratio (ACR), blood glucose, lipid profile, electrolytes, and 12-lead ECG. 1, 2

• Echocardiography is indicated if ECG abnormalities or cardiac symptoms are present 1
• Fundoscopy is recommended when BP >180/110 mmHg to evaluate for hypertensive emergency 1
• Screen for secondary hypertension if: age <30 years requiring treatment, resistant hypertension (≥3 drugs), sudden onset/worsening, or suggestive clinical features 1

Cardiovascular Risk Stratification

Use SCORE2 (ages 40-69) or SCORE2-OP (ages ≥70) to assess 10-year CVD risk, with patients having ≥10% risk considered high-risk regardless of age. 1

• Patients with established CVD, moderate-to-severe CKD (eGFR <60), diabetes, or hypertension-mediated organ damage (HMOD) are automatically considered high-risk 1
• High-risk designation mandates more aggressive BP targets and immediate pharmacotherapy 1

Blood Pressure Targets

The target blood pressure for most adults is 120-129 mmHg systolic and <80 mmHg diastolic when treatment is well tolerated. 1, 2

• For patients with diabetes, CKD, or established CVD: target <130/80 mmHg 1, 2, 3
• For adults ≥65 years: target systolic <130 mmHg 3, 4
• Minimum acceptable control (audit standard): <150/90 mmHg for general population, <140/80 mmHg for high-risk patients 1

Lifestyle Modifications (Universal Recommendations)

All patients with BP >120/80 mmHg should receive comprehensive lifestyle counseling, which can lower systolic BP by 4-11 mmHg and should be implemented alongside pharmacotherapy, not as a delay to treatment. 1, 2, 3

Dietary Interventions

• Sodium restriction to <2 g/day (equivalent to ~5 g salt/day) reduces SBP by 5-8 mmHg 1, 3
• DASH or Mediterranean diet emphasizing 8-10 servings/day of fruits and vegetables, low-fat dairy (2-3 servings/day), whole grains, and reduced saturated fat 1, 2, 3, 5
• Potassium supplementation through dietary sources (fruits/vegetables) unless contraindicated by CKD 3, 4
• Limit free sugar to <10% of energy intake, particularly avoiding sugar-sweetened beverages 1

Weight Management

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women), with approximately 1 mmHg SBP reduction per 1 kg weight loss 1, 2, 4

Physical Activity

• Minimum 150 minutes/week of moderate-intensity aerobic exercise (30 minutes, 5-7 days/week) plus resistance training 2-3 times/week reduces SBP by 4-9 mmHg 1, 2, 3

Alcohol Restriction

• Limit to <100 g/week of pure alcohol (approximately ≤2 drinks/day for men, ≤1 drink/day for women), with complete abstinence preferred for optimal health outcomes 1, 3, 4

Smoking Cessation

• Complete tobacco cessation with referral to cessation programs is mandatory as smoking independently causes CVD 1, 3

Pharmacological Treatment Initiation

For office BP ≥140/90 mmHg, initiate both lifestyle modifications AND antihypertensive medication simultaneously—do not delay pharmacotherapy for a trial of lifestyle changes alone. 1, 3

When to Start Medications

• Immediate treatment: BP ≥140/90 mmHg regardless of CVD risk 1, 2
• Immediate treatment: BP 130-139/80-89 mmHg with high CVD risk (≥10% 10-year risk, diabetes, CKD, or established CVD) 1, 3, 4
• Exception: Adults >80 years should be treated only when office SBP ≥160 mmHg 1

First-Line Combination Therapy

Most patients should start with two-drug combination therapy, preferably as a single-pill combination to improve adherence. 1, 2, 3

Preferred initial combinations for non-Black patients:

1. ACE inhibitor or ARB + dihydropyridine calcium channel blocker (DHP-CCB) 1, 2, 3
2. ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1, 2, 3

For Black patients: ARB + DHP-CCB OR DHP-CCB + thiazide/thiazide-like diuretic (due to reduced response to ACE inhibitors as monotherapy) 3

For Sub-Saharan African patients: CCB + thiazide diuretic OR CCB + RAS blocker 1

Specific Drug Selection

First-line agents include:

• ACE inhibitors (e.g., lisinopril 10-40 mg daily, enalapril) 3, 6, 4
• ARBs (e.g., losartan, candesartan) 3, 6, 4
• Thiazide-like diuretics (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 3, 4, 7
• DHP calcium channel blockers (e.g., amlodipine 5-10 mg daily) 3, 4

Monotherapy Considerations

Single-agent therapy may be considered only for:

• BP 130-149/80-89 mmHg with low-moderate CVD risk 3
• Frail elderly patients where combination therapy may cause excessive BP lowering 1

Special Population Considerations

Diabetes Mellitus

• ACE inhibitor or ARB is mandatory as first-line therapy to reduce progression of diabetic nephropathy 3, 6
• Target BP <130/80 mmHg 1, 3
• For diabetic nephropathy with proteinuria (UACR ≥300 mg/g): losartan reduces doubling of serum creatinine and progression to ESRD 6

Chronic Kidney Disease

• ACE inhibitor or ARB for patients with albuminuria (UACR ≥30 mg/g) to reduce progressive kidney disease 3
• Target BP <130/80 mmHg 1, 3
• Monitor serum creatinine and potassium 7-14 days after initiation or dose changes 3
• Avoid ACE inhibitors/ARBs in severe bilateral renal artery stenosis (risk of acute renal failure) 3

Coronary Artery Disease

• ACE inhibitor or ARB as first-line therapy 3
• Beta-blockers indicated if history of myocardial infarction or heart failure 3

Heart Failure

• Combination of ACE inhibitor/ARB, beta-blocker, diuretic, and mineralocorticoid receptor antagonist per heart failure guidelines 2, 3

Pregnancy or Planning Pregnancy

• Absolute contraindications: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors (aliskiren), neprilysin inhibitors (cause fetal injury/death) 3, 8
• Preferred agents: Methyldopa, nifedipine, or labetalol 1

Left Ventricular Hypertrophy

• Losartan reduces stroke risk in hypertensive patients with LVH, though this benefit does not apply to Black patients 6

Titration Strategy and Follow-Up

Achieve BP control within 3 months with monthly follow-up visits until target is reached. 2, 3

Escalation Algorithm

1. Start with two-drug combination (ACE inhibitor/ARB + CCB or thiazide) 1, 3
2. If BP not controlled after 1 month: Increase to full doses of both agents before adding third drug 3
3. If BP not controlled with two drugs at full dose: Add third drug from different class to create triple therapy (ACE inhibitor/ARB + CCB + thiazide) 1, 3
4. If BP not controlled with triple therapy: Proceed to resistant hypertension protocol 1

Monitoring Parameters

• Recheck BP in 1 month after any medication change 3
• Monitor serum creatinine and potassium 7-14 days after starting/changing ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 3
• Monitor for hypokalemia with diuretic therapy 3
• Home BP monitoring facilitates medication titration and maintenance of goals 2

Resistant Hypertension Management

Resistant hypertension is defined as BP not controlled despite optimal doses of three drugs (including a diuretic), or controlled BP requiring ≥4 drugs. 1

Systematic Approach

1. Confirm true resistance: Verify adherence, exclude white coat effect with ABPM, review for interfering substances (NSAIDs, decongestants, licorice) 1
2. Reinforce lifestyle measures, especially sodium restriction to <2 g/day 1
3. Optimize triple therapy: Ensure full doses of ACE inhibitor/ARB + CCB + thiazide-like diuretic 1, 3
4. Add spironolactone 25-50 mg daily as fourth-line agent (most effective for resistant hypertension) 1, 3
5. If spironolactone not tolerated/effective: Consider eplerenone, amiloride, higher-dose thiazide, or loop diuretic 1
6. Fifth-line options: Beta-blocker (bisoprolol), alpha-blocker (doxazosin), centrally acting agent, or hydralazine 1, 3
7. Catheter-based renal denervation may be considered at high-volume centers after multidisciplinary assessment and shared decision-making 1

Acute Hypertension Management

Hypertensive Emergency (with end-organ damage)

• Immediate IV therapy required with agents such as labetalol, nicardipine, or clevidipine 1
• Goal: Reduce BP by 10-15% in first hour, then gradually to 160/100 mmHg over next 2-6 hours 1

Acute Intracerebral Hemorrhage

• Do NOT lower BP if SBP <220 mmHg 1
• If SBP ≥220 mmHg: Careful IV lowering to <180 mmHg should be considered 1

Acute Ischemic Stroke or TIA

• For TIA: Start/resume antihypertensive treatment immediately 1
• For ischemic stroke: Delay antihypertensive treatment for several days 1

Severe Hypertension in Pregnancy

• IV labetalol, oral methyldopa, or oral nifedipine are first-line 1
• IV hydralazine is second-line option 1

Adjunctive Cardiovascular Risk Reduction

Antiplatelet Therapy

• Aspirin 75 mg daily for secondary prevention in all patients unless contraindicated 1
• Aspirin 75 mg daily for primary prevention if age ≥50 years, BP controlled to <150/90 mmHg, and either target organ damage, diabetes, or 10-year CVD risk ≥20% 1

Statin Therapy

• Initiate statin for all patients with hypertension and established CVD (secondary prevention) if total cholesterol ≥3.5 mmol/L 1
• Initiate statin for primary prevention if 10-year CVD risk ≥20% and total cholesterol ≥3.5 mmol/L 1
• Target: Reduce total cholesterol by 25% or LDL by 30%, or achieve total cholesterol <4.0 mmol/L or LDL <2.0 mmol/L, whichever provides greater reduction 1

Common Pitfalls to Avoid

• Never delay pharmacotherapy for a 3-6 month trial of lifestyle changes when BP ≥140/90 mmHg—this outdated approach increases CVD risk 3
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available (inferior cardiovascular outcomes) 3
• Do not use beta-blockers as initial therapy unless specific indication exists (heart failure, post-MI, coronary disease) 3
• Do not diagnose hypertension based on single office reading—confirm with out-of-office measurements 1
• Do not overlook white coat hypertension—use ABPM/HBPM when office readings are elevated but patient appears low-risk 1
• Avoid ACE inhibitors in patients with history of angioedema (use ARB, CCB, or other class instead) 3
• Do not use thiazides in active gout unless patient is on uric acid-lowering therapy 3
• Never prescribe ACE inhibitors, ARBs, or aliskiren in pregnancy or women planning pregnancy 3, 8

Expected Benefits of BP Control

Effective blood pressure reduction provides substantial cardiovascular protection:

• 35-40% reduction in stroke incidence 2
• 20-30% reduction in myocardial infarction with 10 mmHg SBP reduction 2, 4
• 50% reduction in heart failure 2
• One death prevented for every 11 patients treated when 12 mmHg SBP reduction is maintained over 10 years in patients with additional CVD risk factors 2

Implementation Strategy

Team-based care is the most effective approach for achieving BP control, utilizing nurses, pharmacists, and other health professionals for patient education, medication management, and lifestyle counseling. 2

• Simplify regimens to once-daily dosing with single-pill combinations whenever possible 2, 3
• Address financial barriers and minimize medication costs 2
• Encourage home BP monitoring with validated devices 2
• Provide clear written information and reinforce lifestyle modifications at each visit 1