What is the recommended treatment approach for a patient with hypertension in an outpatient setting, considering comorbidities such as diabetes and kidney disease?

Hypertension Outpatient Dot Phrase

Blood Pressure Assessment & Diagnosis

• Blood pressure measured at today's visit: [/] mmHg 1
• Confirmed hypertension diagnosis with readings ≥130/80 mmHg on separate occasions 1
• Home blood pressure monitoring confirms sustained hypertension (≥135/85 mmHg average) 1
• Orthostatic blood pressure checked to assess for autonomic neuropathy (particularly in diabetic patients) 1

Comorbidity Assessment

• Diabetes mellitus: [Yes/No] - If yes, check urine albumin-to-creatinine ratio 1
• Chronic kidney disease: [Yes/No] - Current eGFR: [___] mL/min/1.73m² 1
• Coronary artery disease: [Yes/No] 1
• Heart failure: [Yes/No] - If yes, ejection fraction: [___]% 1
• Albuminuria: UACR [___] mg/g creatinine 1

Blood Pressure Target

• Target BP: <130/80 mmHg for most patients with diabetes or high cardiovascular risk 1
• Target BP: <140/90 mmHg minimum for lower-risk patients 1
• For patients ≥65 years: Target SBP <130 mmHg if tolerated 2

Lifestyle Modifications Prescribed

All patients receive comprehensive lifestyle therapy regardless of medication status 1:

• Sodium restriction: <1500 mg/day (or reduce by ≥1000 mg/day) 1
• Potassium supplementation: 3500-5000 mg/day through diet 1
• Weight loss: Target ≥1 kg reduction if overweight/obese 1
• Physical activity: 90-150 minutes/week of aerobic exercise 1
• Alcohol limitation: ≤2 drinks/day (men), ≤1 drink/day (women) 1
• DASH diet: Emphasizing fruits, vegetables, whole grains, low-fat dairy, reduced saturated fat 1, 3

Pharmacologic Treatment Algorithm

Initial Monotherapy (BP 130-159/80-99 mmHg)

For patients with diabetes AND albuminuria (UACR ≥30 mg/g):

• ACE inhibitor (e.g., lisinopril 10 mg daily) OR ARB (e.g., losartan 50 mg daily) at maximum tolerated dose 1
• This is MANDATORY for UACR ≥300 mg/g creatinine 1

For patients WITHOUT albuminuria or diabetes:

• Start with thiazide-like diuretic (chlorthalidone 12.5-25 mg daily preferred over HCTZ), ACE inhibitor/ARB, OR calcium channel blocker (amlodipine 5-10 mg daily) 1, 2

Dual Therapy (BP not controlled on monotherapy)

Standard combination for most patients:

• ACE inhibitor/ARB + calcium channel blocker (dihydropyridine) 1, 4
• Example: Lisinopril 20 mg + amlodipine 10 mg daily 1

Alternative for Black patients or volume-dependent hypertension:

• Calcium channel blocker + thiazide-like diuretic 4, 5
• Example: Amlodipine 10 mg + chlorthalidone 25 mg daily 4

Prompt Dual Therapy (BP ≥160/100 mmHg)

• Initiate TWO drugs immediately or single-pill combination 1
• Preferred: ACE inhibitor/ARB + calcium channel blocker OR thiazide diuretic 1

Triple Therapy (BP not controlled on dual therapy)

Standard triple combination:

• ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic 1, 4
• Example: Lisinopril 40 mg + amlodipine 10 mg + chlorthalidone 25 mg daily 4
• This represents guideline-recommended triple therapy with complementary mechanisms 5

Resistant Hypertension (BP ≥140/90 on triple therapy)

Before adding fourth agent, confirm:

• Medication adherence verified 1
• White coat hypertension ruled out with home/ambulatory monitoring 1
• Secondary causes excluded (primary aldosteronism, renal artery stenosis, sleep apnea) 1

Fourth-line agent:

• Add spironolactone 25-50 mg daily (preferred mineralocorticoid receptor antagonist) 1
• Monitor potassium closely when combined with ACE inhibitor/ARB 1

Monitoring Parameters

• Serum creatinine/eGFR and potassium: Check at baseline, 2-4 weeks after starting/titrating ACE inhibitor/ARB/diuretic, then annually 1
• Blood pressure reassessment: 2-4 weeks after medication initiation/adjustment 1
• Goal achievement timeline: Target BP within 3 months of treatment initiation/modification 1
• Annual monitoring: Blood pressure at every routine visit 1

Medication Contraindications & Cautions

• Never combine ACE inhibitor + ARB (increases adverse events without benefit) 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem/verapamil) in heart failure with reduced ejection fraction 1
• Beta-blockers only indicated for specific comorbidities (prior MI, angina, heart failure with reduced EF), not routine hypertension 1
• Monitor for hyperkalemia when using ACE inhibitor/ARB, especially with eGFR <30 mL/min/1.73m² 1

Specialist Referral Criteria

Refer to hypertension specialist if:

• BP ≥140/90 mmHg despite four-drug therapy at optimal doses 1
• Significant renal disease (eGFR <30 mL/min/1.73m²) 1
• Multiple drug intolerances 1
• Suspected secondary hypertension 1

Current Medications Prescribed

• [Medication name] [dose] [frequency] - [indication/rationale]
• [Medication name] [dose] [frequency] - [indication/rationale]

Follow-up Plan

• Return visit in [2-4 weeks/3 months] for BP recheck and medication titration 1
• Home BP monitoring log review at next visit 1
• Laboratory monitoring (creatinine, potassium) scheduled for [date] 1