What is the treatment algorithm for an adult patient with hypertension (HTN) and no comorbidities?

Hypertension Treatment Algorithm for Adults Without Comorbidities

For adults with hypertension and no comorbidities, initiate treatment based on blood pressure stage and cardiovascular risk: start with lifestyle modifications alone for elevated BP or stage 1 hypertension with low cardiovascular risk, but add pharmacotherapy immediately for stage 1 hypertension with 10-year ASCVD risk ≥10% or for stage 2 hypertension, targeting a blood pressure <130/80 mm Hg. 1, 2

Initial Classification and Risk Stratification

• Elevated BP (120-129/<80 mm Hg): Implement lifestyle modifications only and reassess BP in 3-6 months 1, 2
• Stage 1 Hypertension (130-139/80-89 mm Hg): Calculate 10-year ASCVD risk to determine treatment approach 1
  • If ASCVD risk <10%: Start with lifestyle modifications alone, reassess in 3-6 months 1
  • If ASCVD risk ≥10%: Initiate both lifestyle modifications AND pharmacotherapy, reassess in 1 month 1, 2
• Stage 2 Hypertension (≥140/90 mm Hg): Immediately start combination therapy with lifestyle modifications PLUS two antihypertensive drugs from different classes, reassess in 1 month 1
• Hypertensive urgency (≥180/110 mm Hg): Prompt evaluation and immediate antihypertensive treatment within 1 week 1

Lifestyle Modifications (All Patients)

Implement the following evidence-based interventions, which can reduce systolic BP by approximately 3.5 mm Hg and cardiovascular disease risk by 30%: 3

• Weight management: Achieve and maintain BMI in healthy range (most effective single intervention) 2, 4
• Sodium restriction: Limit intake to <2,300 mg/day, ideally <1,500 mg/day 2, 4
• Potassium supplementation: Increase dietary potassium intake 2, 4
• DASH diet: Adopt dietary approaches to stop hypertension eating pattern (most effective dietary intervention) 5, 4
• Alcohol limitation: Maximum 2 standard drinks/day (14/week for men, 9/week for women) 2, 4
• Regular exercise: At least 150 minutes of moderate-intensity aerobic activity weekly 2, 4

Pharmacotherapy Algorithm

First-Line Drug Selection

Initial monotherapy (for stage 1 HTN with ASCVD risk ≥10%): Choose ONE agent from: 1, 2

• Thiazide-type diuretic (chlorthalidone preferred over hydrochlorothiazide based on trial evidence) 1
• ACE inhibitor or ARB
• Calcium channel blocker (dihydropyridine type like amlodipine) 6

Initial dual therapy (for stage 2 HTN or BP >20/10 mm Hg above target): Start with TWO agents, preferably as single-pill combination: 1, 2

• RAS blocker (ACE inhibitor or ARB) PLUS
• Dihydropyridine calcium channel blocker OR thiazide-like diuretic 1, 2

Titration Strategy

If BP remains above goal on dual therapy: 2

• Switch to triple-drug single-pill combination: ACE inhibitor or ARB + calcium channel blocker + thiazide-like diuretic 1, 2

If BP remains above goal on triple therapy: 2

• Add spironolactone as preferred fourth agent 1, 2
• Alternative fourth agents: other diuretic, α-blocker, or β-blocker 1
• Consider referral to hypertension specialist 1

Critical Medication Warnings

Never combine: ACE inhibitor + ARB + renin inhibitor simultaneously (potentially harmful) 1, 2

Blood Pressure Targets

• Adults <65 years: <130/80 mm Hg 2, 4
• Adults ≥65 years: <130 mm Hg systolic (if tolerated and ambulatory, community-dwelling, non-institutionalized) 1, 2

Follow-Up Schedule

• Normal BP: Reassess annually 1
• Elevated BP or stage 1 HTN (low risk): Reassess in 3-6 months after lifestyle modifications 1
• Stage 1 HTN (high risk) or stage 2 HTN: Reassess in 1 month after initiating treatment 1
• Very high BP (≥180/110): Prompt evaluation and treatment initiation within 1 week 1

Confirming Diagnosis and Avoiding Pitfalls

Before initiating treatment: 2

• Confirm diagnosis with accurate office BP measurements using proper technique 2
• Obtain home BP monitoring or 24-hour ambulatory BP monitoring to exclude white coat hypertension 2
• Assess for medication non-adherence in patients not responding to therapy 1
• Screen for secondary causes if resistant hypertension develops 1
• Discontinue interfering substances (NSAIDs, stimulants, oral contraceptives) 1

Special considerations for older adults: 1

• Initiate therapy cautiously, especially with two-drug combinations 1
• Monitor carefully for orthostatic hypotension and adverse effects 1
• Titrate medications slowly with close monitoring 1

Enhancing Treatment Adherence

• Utilize team-based care with multidisciplinary approach 2
• Prescribe once-daily dosing when possible 1
• Use single-pill combination products to improve adherence 1
• Implement motivational interviewing and goal-setting strategies 2
• Employ electronic health records, patient registries, and telehealth strategies 1, 2