What is the recommended treatment approach for a patient with hypertension, considering lifestyle modifications and medication options?

Treatment for Hypertension

Blood Pressure Targets

For most adults, target blood pressure should be <130/80 mmHg, with an optimal systolic target of 120-129 mmHg if well tolerated 1. For patients ≥65 years, target systolic blood pressure <130 mmHg 1. Higher-risk patients including those with diabetes, chronic kidney disease, or established cardiovascular disease require the stricter <130/80 mmHg target 1.

Lifestyle Modifications (Initiate Immediately)

Lifestyle modifications should be initiated simultaneously with pharmacological therapy in confirmed hypertension, not sequentially 1. These interventions provide additive blood pressure reductions of 10-20 mmHg 2:

• Sodium restriction to <2g/day produces 5-10 mmHg systolic reduction, with greater benefit in elderly patients 1, 3
• Weight reduction to achieve BMI 20-25 kg/m² leads to 6.0 mmHg systolic and 4.6 mmHg diastolic reduction 1
• DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy, reduced saturated fat) reduces systolic and diastolic BP by 11.4 and 5.5 mmHg respectively 4, 5
• Regular aerobic exercise (90-150 min/week) produces 4 mmHg systolic and 3 mmHg diastolic reduction 4, 1
• Alcohol moderation (≤2 drinks/day in men, ≤1/day in women) 4
• Potassium supplementation (3500-5000 mg/day) 4

Pharmacological Treatment Algorithm

Initial Therapy

Start immediately with two-drug combination therapy rather than monotherapy for confirmed hypertension (BP ≥140/90 mmHg) 1. The preferred first-line combination is a RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic 1, 3.

For non-Black patients: Start with ACE inhibitor or ARB + calcium channel blocker 1

For Black patients: Start with calcium channel blocker + thiazide diuretic (this combination is more effective than calcium channel blocker + ACE inhibitor/ARB in this population) 2

Second-Line Therapy (If BP Remains Uncontrolled)

Add a thiazide or thiazide-like diuretic as the third agent to achieve guideline-recommended triple therapy: RAS blocker + calcium channel blocker + thiazide diuretic 2, 1. Chlorthalidone 12.5-25mg daily is preferred over hydrochlorothiazide 25-50mg daily due to its longer duration of action and superior cardiovascular outcomes 2, 3.

Third-Line Therapy (Resistant Hypertension)

Add spironolactone 25-50mg daily as the preferred fourth-line agent for resistant hypertension (BP >140/90 mmHg despite three medications including a diuretic at optimal doses) 2, 1. This provides additional BP reductions of 20-25/10-12 mmHg when added to triple therapy 2.

Alternative fourth-line agents if spironolactone is contraindicated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 2.

Specific Comorbidity Considerations

• Chronic kidney disease or diabetes with albuminuria: Favor ACE inhibitor or ARB 4
• Heart failure: Favor ACE inhibitor or ARB; avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) 4, 2
• Atrial fibrillation: Favor ARB to reduce recurrence 4
• Coronary artery disease: ACE inhibitor or ARB + amlodipine combination is particularly beneficial 2
• Aortic disease: Favor beta-blockers 4

Monitoring and Follow-Up

• See patients every 1-3 months until BP is controlled 1
• Achieve target BP within 3 months of treatment initiation or modification 2, 1
• Allow 2-4 weeks for full effect of dose adjustments before further changes 6, 1
• Monitor serum potassium and creatinine 2-4 weeks after initiating diuretic therapy or RAS blockers 2
• Confirm diagnosis with out-of-office measurements: home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 1

Critical Pitfalls to Avoid

• Do not combine ACE inhibitor with ARB – this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit 2, 1
• Do not add beta-blocker as third agent unless compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, rate control need) – beta-blockers are less effective than diuretics for stroke prevention 2
• Do not delay treatment intensification in stage 2 hypertension (≥160/100 mmHg) – prompt action reduces cardiovascular risk 2
• Verify medication adherence before adding agents – non-adherence is the most common cause of apparent treatment resistance 2, 6
• Screen for secondary hypertension if BP remains severely elevated despite optimal therapy: primary aldosteronism (20% prevalence in resistant hypertension), sleep apnea, renal artery stenosis, interfering medications (NSAIDs) 4, 2

Referral Indications

Refer to hypertension specialist if BP remains uncontrolled (≥160/100 mmHg) despite four-drug therapy at optimal doses, or if multiple drug intolerances exist 2, 1.