What is the initial treatment approach for a 59-year-old female with a new diagnosis of hypertension, considering her age, sex, and potential comorbidities such as diabetes or chronic kidney disease?

Initial Workup and Management of New Hypertension in a 59-Year-Old Female

For a 59-year-old woman with newly diagnosed hypertension, immediately confirm the diagnosis with out-of-office blood pressure monitoring, initiate lifestyle modifications, and start dual-drug combination therapy if blood pressure is ≥140/90 mmHg or if BP is 130-139/80-89 mmHg with high cardiovascular risk. 1, 2

Diagnostic Confirmation

Blood pressure measurement technique:

• Use a validated automated upper arm cuff with appropriate cuff size, measuring BP in both arms at first visit and using the arm with higher readings for subsequent measurements 3
• Confirm hypertension with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) rather than relying solely on office readings 1, 2
• Office BP ≥130/85 mmHg requires confirmation before diagnosis 3

Essential baseline investigations:

• Urine strip test for blood and protein, serum electrolytes and creatinine, blood glucose, total:HDL cholesterol ratio, and 12-lead electrocardiogram 2
• Calculate 10-year cardiovascular disease risk and screen for target organ damage, diabetes, chronic kidney disease, or established cardiovascular disease 2

Screen for secondary hypertension if:

• Age <40 years at diagnosis (though this patient is 59, so less likely) 1
• Resistant hypertension develops later (BP uncontrolled on three drugs) 1
• Look specifically for primary aldosteronism, renal artery stenosis, obstructive sleep apnea, and medication interference 4

Lifestyle Modifications (Initiate Immediately for All Patients)

Dietary interventions:

• Sodium restriction to <1,500 mg/day or at minimum reduce by 1,000 mg/day 1
• Follow DASH diet rich in fruits (8-10 servings daily), vegetables, whole grains, and low-fat dairy products (2-3 servings daily) with reduced saturated and total fat 1, 3
• Increase dietary potassium intake to 3,500-5,000 mg/day 1
• Limit alcohol to ≤1 drink per day for women 1

Weight and physical activity:

• Achieve and maintain BMI between 18.5-24.9 kg/m² and waist circumference <35 inches 1
• Aerobic or dynamic resistance exercise 90-150 minutes per week, or isometric resistance 3 sessions per week 1
• At least 150 minutes of moderate-intensity aerobic activity per week 3

Pharmacological Treatment Decision Algorithm

Start drug therapy immediately if:

• BP ≥140/90 mmHg confirmed on out-of-office monitoring 1, 2
• BP 130-139/80-89 mmHg with high cardiovascular risk (existing CVD, chronic kidney disease, diabetes, target organ damage, or 10-year CVD risk >10%) 1, 3

Initial drug regimen:

• Start with two-drug combination therapy rather than monotherapy for confirmed hypertension (BP ≥140/90 mmHg) 1, 2
• Use fixed-dose single-pill combinations when available to improve adherence 2
• Preferred first-line combination: RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic 1, 2

Specific drug selection for this 59-year-old woman:

If no comorbidities:

• Start ACE inhibitor (lisinopril 10 mg daily) 5 or ARB (losartan 50 mg daily) 6 PLUS amlodipine 5 mg daily 4
• Alternative: ACE inhibitor or ARB PLUS hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily (chlorthalidone preferred for longer duration of action) 4, 2

If diabetes with albuminuria (UACR ≥30 mg/g):

• ACE inhibitor or ARB is mandatory as first-line therapy 1, 3
• Add calcium channel blocker or thiazide diuretic as second agent 1

If chronic kidney disease:

• ACE inhibitor or ARB is mandatory (ARB if ACE inhibitor not tolerated) 1, 7
• Add dihydropyridine calcium channel blocker (always in combination with RAS blocker, never as monotherapy in proteinuric CKD) 7

If heart failure with preserved ejection fraction:

• Diuretics for volume overload, add ACE inhibitor or ARB and beta blocker for incremental BP control 1

If coronary artery disease or post-MI:

• Beta blocker plus ACE inhibitor or ARB 1, 3

Blood Pressure Targets

Target BP for most patients:

• Systolic BP 120-129 mmHg if well tolerated 1
• Minimum target <140/90 mmHg 1, 2
• For high-risk patients (diabetes, CKD, CVD), target <130/80 mmHg 1

If treatment poorly tolerated:

• Target systolic BP "as low as reasonably achievable" (ALARA principle) rather than discontinuing therapy 1

Monitoring Schedule

Initial follow-up:

• See patient monthly for drug titration until BP is controlled 1
• Check serum potassium and creatinine 2-4 weeks after initiating RAS blockers or diuretics 2
• Achieve target BP within 3 months of treatment initiation 3, 2

If BP not controlled on dual therapy:

• Increase to three-drug combination: RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably in single-pill combination 1
• Do NOT combine two RAS blockers (ACE inhibitor + ARB) as this increases adverse events without additional benefit 1

If BP remains uncontrolled on triple therapy:

• Add spironolactone 25-50 mg daily as preferred fourth-line agent for resistant hypertension 4
• Consider referral to hypertension specialist 4

Critical Pitfalls to Avoid

• Never start with monotherapy alone for confirmed hypertension (BP ≥140/90 mmHg)—combination therapy is recommended from the outset 2
• Never delay pharmacological treatment while attempting lifestyle modifications alone in patients with confirmed hypertension—both should be initiated simultaneously 2
• Never combine ACE inhibitor with ARB—this increases hyperkalemia and acute kidney injury risk without cardiovascular benefit 1, 4
• Never use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with heart failure with reduced ejection fraction 1, 4
• Never assume treatment failure without first confirming medication adherence, as non-adherence is the most common cause of apparent treatment resistance 4
• Before starting or intensifying BP-lowering medication, test for orthostatic hypotension by measuring BP 1 and/or 3 minutes after standing from 5 minutes of sitting/lying 1