What is the initial management for a patient with hypertension?

Initial Management of Hypertension

For patients with confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications and pharmacological therapy simultaneously with a two-drug combination, preferably as a single-pill combination. 1, 2

Confirming the Diagnosis

• Confirm hypertension using out-of-office measurements before initiating treatment: home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg). 1, 2
• Measure BP in both arms at the first visit and use the arm with higher readings for subsequent measurements. 2

Lifestyle Modifications (Initiate Immediately)

All patients with BP >120/80 mmHg should implement the following lifestyle changes:

• Weight management: Achieve and maintain a healthy body mass index through caloric restriction. 1
• DASH diet pattern: Emphasize 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products. 1
• Sodium restriction: Limit intake to <2,300 mg/day; eliminate table salt use. 1
• Potassium intake: Increase through dietary sources (fruits and vegetables). 1
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise per week. 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women. 1
• Smoking cessation: Recommend for all patients. 1

Pharmacological Therapy

Initial Drug Selection

For non-Black patients with BP ≥140/90 mmHg:

• Start with a two-drug combination consisting of a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic. 1, 2
• Preferred combinations:
  • ACE inhibitor (lisinopril 10 mg) + thiazide diuretic (chlorthalidone 12.5-25 mg daily), OR 1
  • ACE inhibitor + dihydropyridine calcium channel blocker (amlodipine 5 mg daily), OR 1
  • ARB + dihydropyridine calcium channel blocker 1, 2
• Use single-pill combinations whenever possible to improve adherence. 1, 2
• Chlorthalidone is preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcome data. 1

For Black patients:

• Start with ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide/thiazide-like diuretic (due to reduced response to ACE inhibitors as monotherapy). 1, 2

Special Population Considerations

• Coronary artery disease: Use ACE inhibitor or ARB as first-line therapy. 1
• Albuminuria (UACR ≥30 mg/g): Include ACE inhibitor or ARB to reduce progressive kidney disease risk. 1
• Heart failure: Add beta-blockers in addition to other agents. 1
• Diabetes or CKD: Include ACE inhibitor or ARB as part of initial therapy. 2
• Pregnancy or planning pregnancy: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors are absolutely contraindicated. 1, 2, 3
• History of angioedema: Avoid ACE inhibitors. 1
• Severe bilateral renal artery stenosis: Avoid ACE inhibitors/ARBs due to acute renal failure risk. 1
• Gout or history of acute gout: Use thiazides cautiously unless on uric acid-lowering therapy. 1

Blood Pressure Targets

• Adults <65 years: Target BP <130/80 mmHg. 1, 2
• Adults 65-85 years: Target systolic BP 120-129 mmHg if well tolerated. 1, 2
• Patients with diabetes, CKD, or established cardiovascular disease: Target BP <130/80 mmHg. 1
• CKD patients (eGFR >30 mL/min/1.73m²): Target systolic BP 120-129 mmHg. 2

Monitoring and Follow-Up

• Baseline laboratory tests: Obtain serum creatinine/eGFR and potassium before starting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 1
• Early follow-up labs: Recheck serum creatinine/eGFR, sodium, and potassium 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 1, 2
• Monitor for hypokalemia when using diuretics. 1
• BP reassessment: Recheck BP in 1 month after initiating therapy. 1
• Goal timeline: Achieve BP control within 3 months, with follow-up every 1-3 months until controlled. 1, 2

Titration Strategy

• If BP not controlled with two drugs, escalate to a three-drug combination (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic). 1
• If BP remains uncontrolled with three drugs, add spironolactone 25 mg daily. 1, 2
• Beta-blockers and alpha-blockers are fourth- or fifth-line agents used when spironolactone is not tolerated or contraindicated. 1

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with BP ≥140/90 mmHg—start both simultaneously. 1
• Avoid combining ACE inhibitors with ARBs, as this increases adverse events without added cardiovascular benefit. 1
• Do not use beta-blockers as initial therapy unless a specific indication exists (heart failure, coronary disease). 1
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available. 1
• Do not use immediate-release nifedipine for hypertensive urgencies. 4