What is the recommended treatment for a patient with hypertension, including those with a history of cardiovascular disease or diabetes?

Hypertension Treatment Recommendations

For patients with hypertension, including those with cardiovascular disease or diabetes, initiate lifestyle modifications immediately for blood pressure >120/80 mmHg, start pharmacologic therapy promptly at BP ≥140/90 mmHg with ACE inhibitors or ARBs as first-line agents (particularly when diabetes or albuminuria is present), and use combination therapy with two drugs for BP ≥160/100 mmHg to achieve a target of <130/80 mmHg. 1, 2

Blood Pressure Thresholds and Treatment Initiation

For Patients with Diabetes or Cardiovascular Disease

• Start lifestyle modifications immediately when BP exceeds 120/80 mmHg, including DASH-style diet, sodium restriction (<2,300 mg/day), weight loss if overweight, alcohol moderation, and increased physical activity 1

• Initiate single-drug pharmacologic therapy promptly at confirmed office BP ≥140/90 mmHg, without waiting beyond 3 months of lifestyle intervention alone 1, 2

• Start two-drug combination therapy immediately at confirmed office BP ≥160/100 mmHg, using drugs demonstrated to reduce cardiovascular events in diabetes 1

• Target BP should be <130/80 mmHg in most patients with diabetes to reduce cardiovascular morbidity and mortality 2, 3

For General Hypertensive Patients

• Begin treatment at BP ≥140/90 mmHg for grade 1 hypertension in high-risk patients (CVD, CKD, diabetes, organ damage, or aged 50-80 years) 1

• For low-moderate risk patients, attempt 3-6 months of lifestyle intervention before starting medications if BP is 140-159/90-99 mmHg 1

First-Line Pharmacologic Therapy

Drug Selection Algorithm

For patients WITH diabetes and albuminuria (UACR ≥30 mg/g):

• ACE inhibitor or ARB at maximum tolerated dose is the mandatory first-line choice to reduce progressive kidney disease risk 1, 2
• If one class is not tolerated, substitute the other 1

For patients WITH diabetes and established coronary artery disease:

• ACE inhibitors or ARBs are recommended first-line therapy for hypertension 1

For patients WITH diabetes but WITHOUT albuminuria or established CAD:

• Choose from ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers as all reduce cardiovascular events in diabetes 1

For non-Black patients without diabetes:

• Start with low-dose ACE inhibitor or ARB, then add dihydropyridine calcium channel blocker, then thiazide-like diuretic 1

For Black patients:

• Start with low-dose ARB plus dihydropyridine calcium channel blocker or dihydropyridine calcium channel blocker plus thiazide-like diuretic 1

The American Diabetes Association guidelines 1 provide the most specific and evidence-based recommendations for patients with diabetes, emphasizing ACE inhibitors and ARBs as preferred agents due to their cardiovascular and renal protective effects beyond blood pressure lowering alone.

Combination Therapy Strategy

• Multiple-drug therapy is generally required to achieve blood pressure targets, particularly in diabetic kidney disease 1

• For BP ≥160/100 mmHg, use two drugs or single-pill combination immediately rather than sequential monotherapy titration 1

• Preferred two-drug combinations include ACE inhibitor or ARB plus dihydropyridine calcium channel blocker, or ACE inhibitor or ARB plus thiazide-like diuretic 2

• Simplify regimens with once-daily dosing and single-pill combinations to improve adherence 1

Critical Contraindications

Never Combine These Medications

• NEVER use ACE inhibitors and ARBs together due to increased risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 1, 2

• NEVER combine ACE inhibitors or ARBs with direct renin inhibitors for the same safety reasons 1

• Beta-blockers should NOT be first-line therapy unless specific indications exist (prior MI, active angina, heart failure with reduced ejection fraction) 2

Monitoring Requirements

• Monitor serum creatinine/eGFR and potassium 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or diuretics, then at least annually 1, 2

• Achieve target BP within 3 months of treatment initiation 1

• Measure BP at every routine diabetes visit and confirm elevated readings on a separate day before initiating treatment 2

Resistant Hypertension Management

• Resistant hypertension is defined as BP ≥140/90 mmHg despite appropriate lifestyle management plus a diuretic and two other antihypertensive drugs from different classes at adequate doses 1

• Before diagnosing resistant hypertension, exclude medication nonadherence, white coat hypertension, and secondary hypertension 1

• Add mineralocorticoid receptor antagonist (spironolactone) when BP remains uncontrolled on triple therapy with ACE inhibitor or ARB, thiazide-like diuretic, and dihydropyridine calcium channel blocker 1

• Alternative fourth-line agents if spironolactone is not tolerated include amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Lifestyle Modifications Specifics

Dietary Interventions

• DASH-style eating pattern with 8-10 servings of fruits and vegetables daily and 2-3 servings of low-fat dairy products daily 1, 2

• Sodium restriction to <2,300 mg/day and increased potassium intake through dietary sources 1, 2

• The DASH diet may be considered the most effective lifestyle treatment for reducing blood pressure 4

Weight and Exercise

• Weight reduction through caloric restriction if overweight or obese, aiming for healthy BMI 1, 2

• At least 150 minutes of moderate-intensity aerobic exercise per week, distributed over at least 3 days with no more than 2 consecutive days without activity 2

• A comprehensive lifestyle intervention combining DASH diet, sodium reduction, weight loss, and exercise can reduce 24-hour ambulatory systolic BP by 9.5 mmHg and diastolic BP by 5.3 mmHg 5

Alcohol Moderation

• Limit alcohol to no more than 2 standard drinks per day for men (maximum 14/week) and 1 drink per day for women (maximum 9/week) 1, 2

Common Pitfalls to Avoid

• Do NOT delay pharmacologic therapy beyond 3 months of lifestyle intervention for BP ≥140/90 mmHg in patients with diabetes or high cardiovascular risk 2

• Do NOT use potassium, calcium, or magnesium supplementation as primary therapy, as these have not shown clinically important BP reduction in people consuming a healthy diet 6

• Do NOT use ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, or neprilysin inhibitors in pregnancy or in sexually active individuals of childbearing potential not using reliable contraception 2

• Do NOT use diuretics for BP control in pregnancy, though they may be used during late-stage pregnancy for volume control if needed 1