What are the guidelines for treating a patient with hypertension (High Blood Pressure), considering lifestyle modifications and pharmacological treatment options?

Guidelines for Hypertension Treatment

Lifestyle modifications are the first-line treatment for all patients with hypertension, and when pharmacological therapy is needed, start with a thiazide or thiazide-like diuretic, ACE inhibitor/ARB, or calcium channel blocker, titrating to achieve a blood pressure target of <130/80 mmHg for most adults under 65 years. 1, 2

Lifestyle Modifications: First-Line for All Patients

All patients with hypertension should implement lifestyle changes, which can prevent or delay the onset of high blood pressure and enhance the effects of antihypertensive medications. 1

Essential Lifestyle Interventions

• Salt reduction: Reduce salt added when preparing foods and at the table; avoid high-salt foods such as soy sauce, fast foods, and processed foods including breads and cereals. 1
• DASH diet: Eat a diet rich in whole grains, fruits, vegetables, polyunsaturated fats, and dairy products while reducing foods high in sugar, saturated fat, and trans fats; increase intake of vegetables high in nitrates such as leafy vegetables and beetroot. 1
• Alcohol moderation: Limit daily alcohol consumption to 2 standard drinks for men and 1.5 for women (10 g alcohol/standard drink); avoid binge drinking. 1
• Weight reduction: Maintain a waist-to-height ratio <0.5 for all populations; particularly manage abdominal obesity using ethnic-specific cut-offs for BMI and waist circumference. 1
• Smoking cessation: Refer to smoking cessation programs, as smoking is a major risk factor for cardiovascular disease, COPD, and cancer. 1
• Regular physical activity: Engage in regular aerobic and resistance exercise. 1
• Stress reduction: Implement stress reduction techniques and mindfulness practices. 1

The DASH diet may be considered the most effective lifestyle treatment for reducing blood pressure among all lifestyle modifications. 3

When to Initiate Pharmacological Treatment

Treatment Algorithm by Blood Pressure Level

• High-normal BP or Grade 1 hypertension without high cardiovascular risk: Use lifestyle modifications first for 3-6 months; if blood pressure remains uncontrolled, then start medication. 3
• Grade 2 hypertension (≥140/90 mmHg) or Grade 1 with high cardiovascular risk: Initiate pharmacological therapy immediately alongside lifestyle modifications. 1, 2

The decision to initiate antihypertensive medication should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk. 2

First-Line Pharmacological Therapy

Initial Drug Selection

First-line drug therapy consists of three classes, which can be used as monotherapy or in combination: 2, 4

• Thiazide or thiazide-like diuretics: Hydrochlorothiazide or chlorthalidone 2
• ACE inhibitors or ARBs: Such as enalapril, lisinopril, losartan, or candesartan 2
• Calcium channel blockers: Such as amlodipine 2

Race-Specific Considerations

• Black patients: Calcium channel blockers or thiazide diuretics are preferred as initial therapy over ACE inhibitors or ARBs. 5
• Non-Black patients: Any of the three first-line classes (ACE inhibitor/ARB, calcium channel blocker, or thiazide diuretic) are appropriate initial choices. 5

Dosing Strategy

• Losartan: Start with 50 mg once daily; can increase to 100 mg once daily as needed (use 25 mg starting dose if volume depleted or on diuretics). 6
• Lisinopril: Titrate according to blood pressure response. 7
• Amlodipine: Start at 5 mg daily; can increase to 10 mg daily. 5

Combination Therapy for Uncontrolled Hypertension

Two-Drug Combination

If blood pressure remains uncontrolled on monotherapy, add a second agent from a different class: 5

• ACE inhibitor/ARB + calcium channel blocker: Provides complementary mechanisms of vasodilation and renin-angiotensin system inhibition. 5
• Calcium channel blocker + thiazide diuretic: Particularly effective for Black patients, elderly patients, or those with volume-dependent hypertension. 5

Three-Drug Combination (Triple Therapy)

When blood pressure is not controlled with two drugs, add a third agent to create the guideline-recommended triple therapy: 5

• ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic: This combination targets different mechanisms—volume reduction, vasodilation, and renin-angiotensin system blockade. 5

Critical pitfall to avoid: Do not add a third drug class before maximizing doses of the current two-drug regimen, as this violates guideline-recommended stepwise approaches. 5

Four-Drug Regimen for Resistant Hypertension

If blood pressure remains uncontrolled despite optimized triple therapy: 5

• Add spironolactone 25-50 mg daily: This is the preferred fourth-line agent for resistant hypertension, providing additional blood pressure reductions of 20-25/10-12 mmHg. 5
• Monitor potassium closely: Hyperkalemia risk is significant when adding spironolactone to an ACE inhibitor or ARB. 5

Never combine an ACE inhibitor with an ARB, as this increases adverse events such as hyperkalemia and acute kidney injury without additional cardiovascular benefit. 5

Blood Pressure Targets

• Adults <65 years: Target <130/80 mmHg 2
• Adults ≥65 years: Target systolic <130 mmHg 2
• Minimum acceptable target for most patients: <140/90 mmHg 5

Achieve target blood pressure within 3 months of initiating or modifying therapy. 5

Monitoring and Follow-Up

• Reassess blood pressure within 2-4 weeks after any medication initiation or dose adjustment. 5
• Check serum potassium and creatinine 2-4 weeks after initiating ACE inhibitor, ARB, or diuretic therapy to detect potential electrolyte abnormalities or changes in renal function. 5
• Confirm adherence before adding additional agents, as nonadherence affects 10-80% of hypertensive patients and is a key driver of suboptimal blood pressure control. 1, 8

Seasonal Blood Pressure Variation

Blood pressure exhibits seasonal variation with lower levels at higher temperatures and higher at lower temperatures, with an average decline in summer of 5/3 mmHg (systolic/diastolic). 1 Consider possible downtitration when symptoms suggesting overtreatment appear with temperature rise, particularly if blood pressure falls below the recommended goal. 1

Special Populations

Patients with Left Ventricular Hypertrophy

Start losartan 50 mg once daily; add hydrochlorothiazide 12.5 mg daily and/or increase losartan to 100 mg once daily, followed by increasing hydrochlorothiazide to 25 mg once daily based on blood pressure response. 6 Note that this benefit does not apply to Black patients. 6

Patients with Type 2 Diabetes and Nephropathy

Start losartan 50 mg once daily; increase to 100 mg once daily based on blood pressure response to reduce the rate of progression of nephropathy. 6

Patients with Hepatic Impairment

In patients with mild-to-moderate hepatic impairment, start losartan at 25 mg once daily. 6

Referral Criteria

Refer to a hypertension specialist if: 5

• Blood pressure remains uncontrolled (≥160/100 mmHg) despite four-drug therapy at optimal doses
• Multiple drug intolerances are present
• Concerning features suggesting secondary hypertension are identified