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

Hypertension Treatment Recommendations

For most adults with hypertension, initiate treatment with lifestyle modifications first, and if pharmacotherapy is needed, start with a thiazide or thiazide-like diuretic, ACE inhibitor/ARB, or calcium channel blocker, titrating to achieve a blood pressure target of <130/80 mmHg for adults under 65 years. 1, 2

Initial Assessment and Diagnosis

• Confirm the diagnosis using home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) in addition to office measurements, as white coat hypertension affects 15-30% of patients 3, 1
• Measure blood pressure annually in patients with normal readings and every 3-6 months in those with elevated blood pressure or stage 1 hypertension not yet on medication 3
• Screen for secondary causes if blood pressure is severely elevated or resistant to treatment, including primary aldosteronism (20% prevalence in resistant hypertension), sleep apnea, renal artery stenosis, and medication interference 3

Lifestyle Modifications (First-Line for All Patients)

Lifestyle changes should be prescribed for all patients with elevated blood pressure or hypertension and can reduce systolic blood pressure by 10-20 mmHg when combined. 3, 4, 2

• Sodium restriction to <1,500 mg/day (or at minimum a 1,000 mg/day reduction) provides 5-10 mmHg systolic reduction 3, 4
• Weight loss if overweight/obese (target ideal body weight or minimum 1 kg reduction; 10 kg loss yields 6.0/4.6 mmHg reduction) 3, 2
• DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy, reduced saturated fat) reduces blood pressure by 11.4/5.5 mmHg 3, 4
• Increased dietary potassium (3,500-5,000 mg/day) for those without contraindications 3, 2
• Regular aerobic exercise (90-150 minutes/week) or dynamic resistance training produces 4/3 mmHg reduction 3, 2
• Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) 3, 2
• Smoking cessation to reduce overall cardiovascular risk 4

When to Initiate Pharmacotherapy

• Stage 1 hypertension (130-139/80-89 mmHg) with high cardiovascular risk (10-year ASCVD risk ≥10%, diabetes, chronic kidney disease, or age ≥65 years): start medication immediately alongside lifestyle modifications 3, 2
• Stage 1 hypertension without high risk: attempt lifestyle modifications for 3-6 months first; if blood pressure remains uncontrolled, initiate medication 3, 4
• Stage 2 hypertension (≥140/90 mmHg): initiate medication immediately with lifestyle modifications 3, 2

First-Line Pharmacotherapy Options

Choose from thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, or calcium channel blockers based on patient characteristics and comorbidities. 1, 2

General Population (Non-Black Adults)

• Start with ACE inhibitor (e.g., lisinopril 10-40 mg daily) or ARB (e.g., losartan 50-100 mg daily) 1, 5, 6
• Alternative: Thiazide-like diuretic (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 1, 2, 7
• Alternative: Calcium channel blocker (amlodipine 5-10 mg daily) 1, 2

Black Patients

• Calcium channel blocker (amlodipine 5-10 mg daily) or thiazide diuretic as preferred initial therapy, as ACE inhibitors/ARBs are less effective as monotherapy in this population 1, 5

Patients with Specific Comorbidities

• Chronic kidney disease or diabetes with albuminuria: ACE inhibitor or ARB (ARB if ACE inhibitor not tolerated) 3, 1
• Heart failure with reduced ejection fraction: ACE inhibitor or ARB 3
• Atrial fibrillation: ARB may reduce recurrence 3
• Coronary artery disease: ACE inhibitor, ARB, or calcium channel blocker 1
• Aortic disease: Beta-blocker 3

Escalation Strategy for Uncontrolled Hypertension

Follow a stepwise approach: optimize first agent → add second agent from different class → optimize both → add third agent → consider fourth agent if resistant. 1, 8

Two-Drug Combination Therapy

• ACE inhibitor/ARB + calcium channel blocker: provides complementary vasodilation and renin-angiotensin system blockade 1
• ACE inhibitor/ARB + thiazide diuretic: effective for volume-dependent hypertension 1
• Calcium channel blocker + thiazide diuretic: particularly effective in Black patients and elderly 1

Three-Drug Combination Therapy (Triple Therapy)

• ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic represents guideline-recommended triple therapy targeting three complementary mechanisms 1
• Chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide 25-50 mg daily 1

Four-Drug Therapy (Resistant Hypertension)

• Add spironolactone 25-50 mg daily as the preferred fourth-line agent, providing additional 20-25/10-12 mmHg reduction 1
• Monitor potassium closely when combining with ACE inhibitor/ARB due to hyperkalemia risk 1
• Alternative fourth-line agents if spironolactone contraindicated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Blood Pressure Targets

• Adults <65 years: <130/80 mmHg 1, 2
• Adults ≥65 years: SBP <130 mmHg 2
• High-risk patients (diabetes, chronic kidney disease, established CVD): <130/80 mmHg 1
• Minimum acceptable target for most patients: <140/90 mmHg 1, 2

Monitoring and Follow-Up

• After initiating or adjusting therapy: reassess within 2-4 weeks 1, 8
• Goal: achieve target blood pressure within 3 months of treatment initiation or modification 1, 8
• Once controlled: follow-up every 3-6 months 3
• Monitor for side effects: hyperkalemia and acute kidney injury with ACE inhibitors/ARBs; hypokalemia, hyperuricemia, and glucose intolerance with thiazide diuretics; peripheral edema with calcium channel blockers 1

Critical Pitfalls to Avoid

• Never combine ACE inhibitor with ARB due to increased adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit 1, 8
• Do not add a third drug class before maximizing doses of the current two-drug regimen 1
• Always verify medication adherence before escalating therapy, as non-adherence is the most common cause of apparent treatment resistance 1, 8
• Do not add beta-blocker as third agent unless compelling indications exist (angina, post-MI, heart failure, atrial fibrillation requiring rate control) 1
• Screen for interfering medications (NSAIDs, decongestants, oral contraceptives) that significantly impair blood pressure control 1

Referral to Hypertension Specialist

• Blood pressure remains uncontrolled (≥140/90 mmHg) despite adherence to four-drug therapy at optimal doses including a diuretic 1, 8
• Suspected secondary hypertension with concerning features 3, 1
• Multiple drug intolerances limiting treatment options 1