Hypertension Management
For patients with confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications AND pharmacological therapy simultaneously with a two-drug combination—do not delay medication for a trial of lifestyle changes alone. 1
Diagnosis Confirmation
Before starting treatment, confirm the diagnosis with out-of-office measurements: 1
- Home BP monitoring: ≥135/85 mmHg confirms hypertension 1
- 24-hour ambulatory monitoring: daytime mean ≥130/80 mmHg confirms hypertension 1
- Office BP 140-159/90-99 mmHg requires confirmation within 1 month 1
- Office BP ≥180/110 mmHg requires immediate exclusion of hypertensive emergency 1
Essential Baseline Workup
Obtain these tests before initiating therapy: 1
- Serum creatinine and eGFR 1
- Urine albumin-to-creatinine ratio (ACR) 1
- Blood glucose and lipid profile 1
- Electrolytes 1
- 12-lead ECG 1
- Echocardiography if ECG abnormalities or cardiac symptoms present 1
Blood Pressure Treatment Thresholds
Immediate pharmacotherapy is indicated for: 1, 2
- BP ≥140/90 mmHg regardless of cardiovascular risk 1, 2
- BP 130-139/80-89 mmHg with high CVD risk (≥10% 10-year risk, diabetes, CKD, or established CVD) 1
Target Blood Pressure Goals
- Most adults: 120-129 mmHg systolic and <80 mmHg diastolic when well tolerated 1, 2
- Diabetes, CKD, or established CVD: <130/80 mmHg 1, 2
- Adults ≥65 years: systolic <130 mmHg 1
Lifestyle Modifications (Implement Immediately Alongside Medication)
- DASH or Mediterranean diet with 8-10 servings/day of fruits and vegetables 1
- Low-fat dairy 2-3 servings/day 1
- Sodium restriction to <2 g/day (approximately 5 g salt/day) reduces SBP by 5-8 mmHg 1, 2
- Potassium supplementation through dietary sources unless contraindicated by CKD 1
- Limit free sugar to <10% of energy intake 1
- Target BMI 20-25 kg/m² 1
- Waist circumference <94 cm (men) or <80 cm (women) 1
- Approximately 1 mmHg SBP reduction per 1 kg weight loss 1, 2
- Minimum 150 minutes/week of moderate-intensity aerobic exercise (30 minutes, 5-7 days/week) 1, 2
- Resistance training 2-3 times/week 1, 2
- Reduces SBP by 4-9 mmHg 1, 2
- Limit to <100 g/week of pure alcohol (≤2 drinks/day for men, ≤1 drink/day for women) 1, 2
- Complete tobacco cessation with referral to cessation programs 1
Initial Pharmacological Therapy
Most patients should start with two-drug combination therapy, preferably as a single-pill combination: 1, 2
For non-Black patients, preferred initial combinations: 1, 3
- ACE inhibitor or ARB + dihydropyridine calcium channel blocker (DHP-CCB) 1, 3
- ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1, 3
For Black patients: 1
- ARB + dihydropyridine calcium channel blocker 1
- Calcium channel blocker + thiazide/thiazide-like diuretic 1
- (ACE inhibitors have reduced efficacy as monotherapy in Black patients) 1
Specific drug examples: 4
- Thiazide-like diuretic: chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide) 4
- ACE inhibitor: lisinopril 10-20 mg daily or enalapril 4
- ARB: losartan or candesartan 5, 4
- Calcium channel blocker: amlodipine 5 mg daily 4
Special Population Considerations
- ACE inhibitor or ARB is mandatory as first-line therapy 1, 3
- Target BP <130/80 mmHg 1, 3
- Reduces progression of diabetic nephropathy 1, 3
Chronic kidney disease with albuminuria (UACR ≥30 mg/g): 1, 3
- ACE inhibitor or ARB required 1, 3
- Target BP <130/80 mmHg 1, 3
- Reduces progressive kidney disease 1, 3
- ACE inhibitor or ARB as first-line therapy 1, 3
- Beta-blockers indicated if history of myocardial infarction or heart failure 1
- Combination of ACE inhibitor/ARB, beta-blocker, diuretic, and mineralocorticoid receptor antagonist per heart failure guidelines 1, 3
Pregnant or planning pregnancy—ABSOLUTE CONTRAINDICATIONS: 1, 3
- ACE inhibitors (cause fetal injury/death) 1, 3
- ARBs (cause fetal injury/death) 1, 3
- Mineralocorticoid receptor antagonists 1, 3
- Direct renin inhibitors (aliskiren) 1, 6
- Neprilysin inhibitors 1
- Preferred agents: methyldopa, nifedipine, or labetalol 1
Titration and Follow-Up Strategy
Achieve BP control within 3 months: 1, 2
- Monthly follow-up visits until target BP reached 1, 2
- Recheck BP in 1 month after any medication change 1
- Monitor serum creatinine and potassium 7-14 days after initiating or changing ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 3
- Monitor for hypokalemia when using diuretics 3
If BP not controlled with two drugs: 1
- Escalate to three-drug combination: ACE inhibitor/ARB + calcium channel blocker + thiazide/thiazide-like diuretic 1
If BP not controlled with three drugs (resistant hypertension): 1
Critical Pitfalls to Avoid
- Never delay pharmacotherapy for a trial of lifestyle modifications alone in patients with BP ≥140/90 mmHg—this is outdated practice; current evidence favors simultaneous initiation 1, 2
- Avoid hydrochlorothiazide when chlorthalidone or indapamide are available (longer-acting thiazide-like diuretics are preferred) 1
- Avoid beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease, post-MI) 1
- Do not start monotherapy when BP is ≥150/90 mmHg or >20/10 mmHg above target—use two-drug combination 3
- Confirm diagnosis with out-of-office measurements before initiating treatment to avoid treating white coat hypertension 1, 2
- Screen for secondary hypertension if: age <30 years requiring treatment, resistant hypertension (≥3 drugs), sudden onset/worsening 1
Cardiovascular Benefits of Treatment
Effective BP control provides: 2