What is the best approach for managing newly diagnosed hypertension in a patient, considering lifestyle modifications and pharmacological interventions?

Management of Newly Diagnosed Hypertension

For newly diagnosed hypertension, initiate lifestyle modifications immediately for all patients with BP >120/80 mmHg, and start pharmacological therapy at BP ≥130/80 mmHg in high-risk patients or ≥140/90 mmHg in average-risk patients, using first-line agents (ACE inhibitors, ARBs, thiazide-like diuretics, or calcium channel blockers) with a target BP <130/80 mmHg for most adults. 1

Initial Assessment and Diagnosis

• Confirm the diagnosis using validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms at first visit and using the arm with higher readings for subsequent measurements 2
• Verify hypertension with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) to rule out white coat hypertension 1, 2
• Assess for target organ damage, cardiovascular risk factors, and screen for secondary causes of hypertension (primary aldosteronism, renal artery stenosis, obstructive sleep apnea) 1, 2

Lifestyle Modifications (Foundation for All Patients)

Lifestyle interventions should be initiated for all patients with BP >120/80 mmHg and continued alongside pharmacological therapy when medications are started. 1

Dietary Interventions

• Follow the DASH eating pattern: 8-10 servings of fruits and vegetables daily, 2-3 servings of low-fat dairy products daily, reduced saturated fat and cholesterol 1, 3
• Restrict sodium intake to <2,300 mg/day (ideally <2,000 mg/day), which can reduce systolic BP by 5-10 mmHg 1, 4
• Increase potassium intake through dietary sources to enhance BP reduction 1, 3

Physical Activity and Weight Management

• Engage in at least 150 minutes of moderate-intensity aerobic activity per week (30-60 minutes on 4-7 days per week), which reduces systolic BP by approximately 4 mmHg 1, 2, 5
• Achieve and maintain healthy body weight (BMI 18.5-24.9 kg/m²) through caloric restriction; a 10 kg weight loss reduces systolic BP by 6.0 mmHg and diastolic BP by 4.6 mmHg 1, 2, 5
• Maintain waist circumference <102 cm for men and <88 cm for women 5

Alcohol and Smoking

• Limit alcohol consumption to ≤2 servings per day for men and ≤1 serving per day for women 1, 2
• Complete smoking cessation for all smokers to reduce overall cardiovascular risk 2

The BP-lowering effects of individual lifestyle components are partially additive and enhance the efficacy of pharmacological therapy, potentially providing 10-20 mmHg systolic reduction when combined. 4, 6

Pharmacological Therapy Initiation

Treatment Thresholds

The decision to initiate antihypertensive medication depends on both BP level and cardiovascular risk: 1, 2, 4

• BP ≥130/80 mmHg in high-risk patients: Start drug therapy immediately alongside lifestyle modifications in patients with established CVD, chronic kidney disease, diabetes, target organ damage, or age 50-80 years 2
• BP ≥140/90 mmHg in average-risk patients: Start drug therapy immediately with lifestyle modifications 1, 2
• BP ≥160/100 mmHg: Initiate prompt treatment with two drugs from different classes plus lifestyle therapy 1

First-Line Pharmacological Agents

Four drug classes are recommended as first-line therapy, with selection based on patient characteristics: 1, 4

For Non-Black Patients Without Compelling Indications

• ACE inhibitors (e.g., lisinopril, enalapril) 7, 4
• Angiotensin receptor blockers (ARBs) (e.g., losartan, candesartan) 4
• Thiazide-like diuretics (chlorthalidone 12.5-25 mg or indapamide preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes) 1, 4
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 8, 4

For Black Patients

• Preferred initial therapy: Dihydropyridine calcium channel blocker or thiazide-like diuretic 2
• Alternative: Consider starting with CCB + thiazide-like diuretic combination 2

Special Populations with Compelling Indications

ACE inhibitors or ARBs are strongly recommended as first-line therapy for: 1

• Patients with albuminuria (UACR ≥300 mg/g creatinine) 1
• Patients with coronary artery disease 1
• Patients with chronic kidney disease 1
• Patients with diabetes mellitus (especially with albuminuria UACR ≥30 mg/g) 1, 2

Beta-blockers plus ACE inhibitors are recommended for: 5

• Patients with recent myocardial infarction 7, 5
• Patients with heart failure 5
• Patients with angina 5

Combination Therapy Strategy

Most patients require multiple drugs to achieve BP control. 1

• For BP ≥160/100 mmHg: Start with two drugs immediately—typically an ACE inhibitor or ARB plus either a calcium channel blocker or thiazide-like diuretic 1
• Single-pill combinations are strongly preferred over separate pills to improve adherence and persistence 1
• Standard triple therapy combination: ACE inhibitor or ARB + calcium channel blocker + thiazide-like diuretic 1

The WHO Essential Medicines List includes single-pill combination antihypertensive medications to facilitate treatment adherence. 1

Blood Pressure Targets

Target BP should be achieved within 3 months of treatment initiation: 1, 2

• <130/80 mmHg for most adults <65 years, patients with diabetes, chronic kidney disease, or established CVD 1, 2
• <130 mmHg systolic for adults ≥65 years 4
• Minimum acceptable target: <140/90 mmHg for all patients 1

Monitoring and Follow-Up

Initial Monitoring

• Reassess BP within 2-4 weeks after initiating or adjusting therapy 1, 2
• Monitor serum creatinine and potassium 7-14 days (or 1-4 weeks) after starting ACE inhibitors, ARBs, or diuretics 2, 9
• Schedule monthly visits until BP target is achieved 2

Home Blood Pressure Monitoring

• Implement home BP monitoring to guide medication adjustments and confirm office readings 1, 2
• Home BP target: <135/85 mmHg (equivalent to office BP <140/90 mmHg) 1

Treatment Intensification Algorithm

If BP remains uncontrolled after 2-4 weeks on monotherapy: 9

1. Optimize the initial agent to maximum tolerated dose before adding a second drug 9
2. Add a second agent from a different class: For patients on ACE inhibitor/ARB, add calcium channel blocker or thiazide-like diuretic 9
3. Add a third agent: If BP remains uncontrolled on two drugs, add the remaining class to achieve triple therapy (ACE inhibitor/ARB + CCB + thiazide-like diuretic) 1
4. Add spironolactone 25-50 mg daily as the preferred fourth-line agent for resistant hypertension if BP remains ≥130/80 mmHg on optimal triple therapy 1, 9

Critical Pitfalls to Avoid

• Do not delay treatment intensification in patients with stage 2 hypertension (≥160/100 mmHg), as prompt action reduces cardiovascular risk 1
• Do not combine ACE inhibitors with ARBs (dual RAS blockade), as this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit 1
• Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with heart failure or left ventricular dysfunction due to negative inotropic effects 1
• Always verify medication adherence before adding additional agents, as non-adherence is the most common cause of apparent treatment resistance 1, 9
• Do not add a third drug class before maximizing doses of the current two-drug regimen, as this violates guideline-recommended stepwise approaches 1
• Screen for interfering medications (NSAIDs, decongestants, oral contraceptives) that can elevate BP 1

Resistant Hypertension

If BP remains uncontrolled (≥130/80 mmHg) despite adherence to four-drug therapy at optimal doses, refer to a hypertension specialist. 9