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

Hypertension Management

For patients with confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications AND pharmacological therapy simultaneously with a two-drug combination—do not delay medication for a trial of lifestyle changes alone. 1

Diagnosis Confirmation

Before starting treatment, confirm the diagnosis using out-of-office measurements rather than relying solely on office readings: 1

• Home BP monitoring: Threshold ≥135/85 mmHg 1
• 24-hour ambulatory BP monitoring: Daytime mean ≥130/80 mmHg 1
• Office BP 140-159/90-99 mmHg requires confirmation within a reasonable timeframe 1
• Office BP ≥160/100 mmHg should be confirmed as soon as possible, preferably within 1 month 1
• Office BP ≥180/110 mmHg requires immediate evaluation to exclude hypertensive emergency 1

Essential Baseline Workup

Obtain the following before initiating therapy: 1

• Serum creatinine and eGFR 1
• Urine albumin-to-creatinine ratio (ACR) 1
• Blood glucose and lipid profile 1
• Electrolytes 1
• 12-lead ECG 1
• Echocardiography if ECG abnormalities or cardiac symptoms present 1
• Fundoscopy when BP >180/110 mmHg 1

Screen for secondary hypertension if: age <30 years requiring treatment, resistant hypertension (≥3 drugs), sudden onset/worsening, or suggestive clinical features. 1

Blood Pressure Targets

Target BP for most adults: 120-129 mmHg systolic and <80 mmHg diastolic when treatment is well tolerated. 1, 2

Specific populations: 1, 2

• Diabetes, CKD, or established CVD: <130/80 mmHg 1, 2
• Adults ≥65 years: Systolic <130 mmHg 1

Pharmacological Treatment Initiation

When to Start Medication

Initiate both lifestyle modifications AND antihypertensive medication simultaneously in the following scenarios: 1, 2

• BP ≥140/90 mmHg regardless of cardiovascular risk 1, 2
• BP 130-139/80-89 mmHg with high CVD risk (≥10% 10-year risk, diabetes, CKD, or established CVD) 1

Initial Drug Regimen

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

Preferred initial combinations for non-Black patients: 1, 3

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

For Black patients: 3

• ARB + dihydropyridine calcium channel blocker, OR 3
• Calcium channel blocker + thiazide/thiazide-like diuretic (due to reduced response to ACE inhibitors as monotherapy) 3

Specific drug examples: 4

• Thiazide-like diuretic: Chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 3
• ACE inhibitor: Lisinopril 10-20 mg daily or Enalapril 4
• ARB: Losartan or Candesartan 5, 4
• Calcium channel blocker: Amlodipine 5 mg daily 4

Lifestyle Modifications (Implement Simultaneously with Medications)

Comprehensive lifestyle counseling should be provided to all patients with BP >120/80 mmHg—these interventions lower systolic BP by 4-11 mmHg and enhance medication efficacy. 1, 2

Dietary Interventions

• Sodium restriction to <2 g/day (equivalent to ~5 g salt/day) reduces SBP by 5-8 mmHg 1, 2, 3
• DASH or Mediterranean diet: 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy, whole grains, reduced saturated fat 1, 2, 3
• Potassium supplementation through dietary sources (fruits/vegetables) unless contraindicated by CKD 1, 3
• 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) 1, 2
• Approximately 1 mmHg SBP reduction per 1 kg weight loss 1, 2

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 Moderation

• 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, 2, 3

Tobacco Cessation

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

Special Population Considerations

Diabetes

• ACE inhibitor or ARB is mandatory as first-line therapy to reduce progression of diabetic nephropathy 1, 3
• Target BP <130/80 mmHg 1, 3

Chronic Kidney Disease (CKD)

• ACE inhibitor or ARB for patients with albuminuria (UACR ≥30 mg/g) to reduce progressive kidney disease 1, 3
• Target BP <130/80 mmHg 1, 3

Coronary Artery Disease

• ACE inhibitor or ARB as first-line therapy 1, 3
• Beta-blockers indicated if history of myocardial infarction or heart failure 1, 3

Heart Failure

• Combination of ACE inhibitor/ARB, beta-blocker, diuretic, and mineralocorticoid receptor antagonist per heart failure guidelines 1, 3

Pregnancy or Planning Pregnancy

Absolute contraindications: 1, 3, 5

• ACE inhibitors 1, 3, 5
• ARBs 1, 3, 5
• Mineralocorticoid receptor antagonists 1, 3
• Direct renin inhibitors (aliskiren) 1, 6
• Neprilysin inhibitors 1

Preferred agents: Methyldopa, nifedipine, or labetalol 1

Titration Strategy and Follow-Up

• Achieve BP control within 3 months with monthly follow-up visits until target is reached 1, 2
• Recheck BP in 1 month after any medication change 1
• If BP not controlled with two drugs, escalate to three-drug combination (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 3
• If BP not controlled with three drugs, add spironolactone 25 mg daily 3
• Monitor serum creatinine and potassium 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 3
• Monitor for hypokalemia when using diuretics 3

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for a trial of lifestyle modifications alone in patients with BP ≥140/90 mmHg 3
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics are preferred 3
• Avoid beta-blockers as initial therapy unless a specific indication exists (heart failure, coronary disease, post-MI) 3
• Do not start monotherapy when BP is ≥150/90 mmHg or >20/10 mmHg above target—use two-drug combination from the outset 3
• Do not fail to confirm diagnosis with out-of-office measurements before initiating treatment to avoid treating white coat hypertension 2

Expected Benefits of BP Control

• 35-40% reduction in stroke incidence 2
• 20-25% reduction in myocardial infarction 2
• 50% reduction in heart failure 2
• For every 12 mmHg reduction in SBP maintained over 10 years, one death is prevented for every 11 treated patients with additional cardiovascular risk factors 2