What are the pillars of hypertension management in adults?

Pillars of Hypertension Management

The pillars of hypertension management consist of lifestyle modifications and pharmacological therapy, with treatment decisions based on blood pressure thresholds, cardiovascular risk, and target organ protection.

Lifestyle Modifications (First Pillar)

Lifestyle interventions form the foundation of hypertension management and should be implemented in all patients, regardless of whether pharmacological therapy is initiated 1, 2.

Dietary Interventions

• Sodium restriction to <2,300 mg/day (ideally <1,500 mg/day) is the single most effective dietary modification 3, 2, 4
• DASH diet pattern: 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 3, 2, 5
• Potassium supplementation: 3,500-5,000 mg/day through dietary sources 3, 4
• Elimination of sugar-sweetened beverages and restriction of free sugar to maximum 10% of energy intake 2

Weight Management

• Maintain body mass index 18.5-24.9 kg/m² and waist circumference <102 cm for men, <88 cm for women 6, 4
• Weight reduction alone can lower BP by approximately 5-20 mm Hg per 10 kg lost 5, 7

Physical Activity

• 30-60 minutes of aerobic exercise on 4-7 days per week 6, 4, 7

Alcohol Moderation

• ≤2 drinks/day for men and ≤1 drink/day for women (maximum 14 units/week for men, 9 units/week for women) 3, 2, 6

Tobacco Cessation

• Complete tobacco cessation with referral to smoking cessation programs 2

Pharmacological Therapy (Second Pillar)

Blood Pressure Thresholds for Initiating Treatment

• Initiate pharmacological therapy at BP ≥140/90 mm Hg for most adults 1
• For high cardiovascular risk patients, consider treatment at lower thresholds based on individualized assessment 1, 8

First-Line Medication Classes

The WHO and major guidelines recommend four classes as first-line agents 1, 2, 4:

1. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)
2. ACE inhibitors or ARBs (e.g., enalapril, candesartan)
3. Long-acting dihydropyridine calcium channel blockers (e.g., amlodipine)
4. Beta-blockers (for patients <60 years or with specific indications like coronary disease) 6, 4

Combination Therapy Strategy

Most adults require more than one agent to achieve target BP 1, 4. The European Society of Cardiology recommends:

• Initial two-drug combination: RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker OR thiazide/thiazide-like diuretic, preferably as a single-pill combination 2
• If BP remains uncontrolled: Escalate to three-drug combination of RAS blocker + calcium channel blocker + thiazide diuretic 2

Special Population Considerations

• Black patients: Initial therapy should include a diuretic or calcium channel blocker 2
• Diabetes mellitus: ACE inhibitor or ARB as first-line; target <130/80 mm Hg 3, 2, 6
• Chronic kidney disease with proteinuria: RAS blockers are first-line due to superior albuminuria reduction 3, 2, 6
• Post-stroke/TIA: Target systolic BP <140 mm Hg to reduce recurrent stroke risk 1
• Heart failure or recent MI: Beta-blockers and ACE inhibitors as first-line 6

Critical contraindication: ACE inhibitors and ARBs are absolutely contraindicated in pregnancy due to fetal harm 3

Blood Pressure Targets (Third Pillar)

Standard Targets

• <140/90 mm Hg for all patients without comorbidities 1, 3
• 120-129 mm Hg systolic for most adults if well tolerated (based on most recent high-quality evidence from European guidelines) 2
• <130/80 mm Hg for patients with diabetes or chronic kidney disease 3, 2, 6

Age-Specific Considerations

• Adults ≥60 years: Target <150 mm Hg systolic is acceptable, though <140 mm Hg may be considered for high-risk patients 1
• Adults <65 years: Target <130/80 mm Hg 4
• Adults ≥65 years: Target systolic <130 mm Hg if tolerated 4

Monitoring and Follow-Up (Fourth Pillar)

• Achieve target BP within 3 months of initiating or intensifying therapy 2
• Home BP monitoring with proper technique is essential for accurate diagnosis and ongoing management 8
• Monitor renal function and potassium at least annually when using ACE inhibitors, ARBs, or diuretics 2
• Maintain treatment lifelong, even beyond age 85, if well tolerated 2

Common Pitfalls to Avoid

• Therapeutic inertia: Failure to intensify therapy when targets are not met is a major barrier to BP control 8
• Inadequate medication adherence assessment: Must be evaluated at each visit 8
• Neglecting lifestyle modifications: These remain essential even when medications are required 8, 7

Clinical Impact

A 10 mm Hg reduction in systolic BP decreases cardiovascular disease events by approximately 20-30% 4. Despite this proven benefit, only 44% of US adults with hypertension have BP controlled to <140/90 mm Hg, and globally only 14% achieve this target 1, 4.