What is the recommended management approach for a patient with hypertension?

Hypertension Management

Diagnosis Confirmation

Before initiating treatment, confirm hypertension with out-of-office measurements using home blood pressure monitoring (≥135/85 mmHg) or ambulatory blood pressure monitoring (daytime mean ≥130/80 mmHg). 1

• Office BP 140-159/90-99 mmHg requires confirmation via home or ambulatory monitoring before starting therapy 1
• Office BP ≥160/100 mmHg should be confirmed as soon as possible, preferably within 1 month 1
• Office BP ≥180/110 mmHg requires immediate evaluation to exclude hypertensive emergency 1

Essential Initial Workup

Obtain baseline laboratory assessment including: 1

• Serum creatinine and eGFR
• Urine albumin-to-creatinine ratio (ACR)
• Blood glucose and lipid profile
• Electrolytes
• 12-lead ECG

Additional testing: 1

• Echocardiography if ECG abnormalities or cardiac symptoms present
• Fundoscopy when BP >180/110 mmHg
• Screen for secondary hypertension if: age <30 years requiring treatment, resistant hypertension (≥3 drugs), sudden onset/worsening, or suggestive clinical features

Blood Pressure Targets

Target systolic BP of 120-129 mmHg and diastolic <80 mmHg for most adults when treatment is well tolerated. 1, 2, 3

• For patients with diabetes, CKD, or established CVD: target <130/80 mmHg 1, 2, 3
• For adults ≥65 years: target systolic <130 mmHg 1

Treatment Initiation Strategy

Initiate both lifestyle modifications AND pharmacological therapy simultaneously—do not delay medication for a trial of lifestyle changes alone. 1, 2

When to Start Medication:

• Immediate treatment for BP ≥140/90 mmHg regardless of CVD risk 1, 2
• Immediate treatment for BP 130-139/80-89 mmHg with high CVD risk (≥10% 10-year risk, diabetes, CKD, or established CVD) 1

Common pitfall: The older recommendation to delay pharmacotherapy for 3-6 months while attempting lifestyle modifications alone is outdated. Current European Society of Cardiology guidelines emphasize simultaneous initiation. 1

Pharmacological Therapy

Most patients should start with two-drug combination therapy, preferably as a single-pill combination to improve adherence. 1, 2

Preferred Initial Combinations (Non-Black Patients):

• ACE inhibitor or ARB + dihydropyridine calcium channel blocker (DHP-CCB) 1, 2
• ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1, 2

For Black Patients:

• ARB + dihydropyridine calcium channel blocker 1
• Calcium channel blocker + thiazide/thiazide-like diuretic 1
• Rationale: Reduced response to ACE inhibitors as monotherapy in this population 1

Specific Drug Considerations:

• Chlorthalidone is preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcome data 1
• Beta-blockers should be avoided as initial therapy unless specific indication exists (heart failure, coronary disease, post-MI) 1

Special Population Considerations

Diabetes:

• ACE inhibitor or ARB is mandatory as first-line therapy to reduce progression of diabetic nephropathy 1, 3
• Target BP <130/80 mmHg 1, 3

Chronic Kidney Disease:

• ACE inhibitor or ARB for patients with albuminuria (UACR ≥30 mg/g) to reduce progressive kidney disease 1, 3
• Target BP <130/80 mmHg 1, 3

Coronary Artery Disease:

• ACE inhibitor or ARB as first-line therapy 1, 3
• Beta-blockers indicated if history of myocardial infarction or heart failure 1

Pregnancy or Planning Pregnancy:

• Absolute contraindications: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors (aliskiren), neprilysin inhibitors—all cause fetal injury/death 1, 3, 4
• Preferred agents: methyldopa, nifedipine, or labetalol 1

Lifestyle Modifications

Implement comprehensive lifestyle counseling alongside pharmacotherapy—these interventions can lower systolic BP by 4-11 mmHg and enhance drug efficacy. 1, 2, 5

Dietary Interventions:

• Sodium restriction to <2 g/day (equivalent to ~5 g salt/day) reduces SBP by 5-8 mmHg 1, 2, 3
• DASH or Mediterranean diet emphasizing 8-10 servings/day of fruits and vegetables, low-fat dairy (2-3 servings/day), whole grains, and reduced saturated fat 1, 2, 3
• Potassium supplementation through dietary sources (fruits/vegetables) unless contraindicated by CKD 1, 3
• Limit free sugar to <10% of energy intake, particularly avoiding sugar-sweetened beverages 1

Weight Management:

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1, 2
• Approximately 1 mmHg SBP reduction per 1 kg weight loss 1, 2, 5

Physical Activity:

• Minimum 150 minutes/week of moderate-intensity aerobic exercise (30 minutes, 5-7 days/week) plus resistance training 2-3 times/week 1, 2, 3
• Reduces SBP by 4-9 mmHg 1, 2, 5

Alcohol Limitation:

• Limit to <100 g/week of pure alcohol (approximately ≤2 drinks/day for men, ≤1 drink/day for women) 1, 2, 3
• Complete abstinence preferred for optimal health outcomes 1

Tobacco Cessation:

• Complete tobacco cessation with referral to cessation programs is mandatory as smoking independently causes CVD 1, 3

Titration and Follow-Up

Achieve BP control within 3 months with monthly follow-up visits until target is reached. 1, 2

Escalation Strategy:

• Recheck BP in 1 month after any medication change 1
• If BP not controlled with two drugs, escalate to three-drug combination (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1
• If BP not controlled with three drugs, add spironolactone 25 mg daily 1

Laboratory Monitoring:

• Monitor serum creatinine and potassium when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1, 3
• Monitor for hypokalemia when using diuretics 3
• Check laboratory values 7-14 days after initiation or dose changes 3

Clinical Benefits of BP Control

Effective blood pressure management provides: 2

• 35-40% reduction in stroke incidence
• 20-25% reduction in myocardial infarction
• 50% reduction in heart failure
• For every 12 mmHg reduction in SBP maintained over 10 years, one death is prevented for every 11 treated patients with additional cardiovascular risk factors