What are the guidelines for managing hypertension (Htn) in a patient, including lifestyle modifications and pharmacological treatment?

Hypertension Management Guidelines

Blood Pressure Targets

For most adults under 65 years, target blood pressure should be <130/80 mmHg, while adults ≥65 years should achieve systolic blood pressure <130 mmHg. 1, 2, 3

• For high-risk patients with diabetes, chronic kidney disease, or established cardiovascular disease, the target is <130/80 mmHg 1, 2
• Confirm diagnosis using home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg), as white coat hypertension affects 15-30% of patients 2

Lifestyle Modifications (First-Line for All Patients)

All patients with blood pressure >120/80 mmHg should implement lifestyle interventions before or alongside pharmacotherapy. 1

Dietary Interventions

• Sodium restriction to <2,300 mg/day (ideally <1,500 mg/day for optimal benefit) 1, 2, 3
• DASH-style eating pattern: 8-10 servings of fruits and vegetables per day, 2-3 servings of low-fat dairy products per day 1
• Increase dietary potassium intake 1
• Weight loss through caloric restriction if overweight or obese (10 kg weight loss reduces systolic BP by 6.0 mmHg and diastolic BP by 4.6 mmHg) 1, 4

Physical Activity and Behavioral Changes

• At least 150 minutes of moderate-intensity aerobic activity per week 1
• Alcohol moderation: no more than 2 drinks per day for men, 1 drink per day for women 1, 3
• Smoking cessation 2

Combined lifestyle modifications can reduce systolic blood pressure by 10-20 mmHg. 2, 3

Pharmacological Treatment Algorithm

When to Initiate Pharmacotherapy

Initiate pharmacotherapy for confirmed office-based blood pressure ≥130/80 mmHg. 1

• For blood pressure ≥160/100 mmHg, promptly initiate two drugs simultaneously in addition to lifestyle therapy 1
• For blood pressure 130-159/80-99 mmHg, start with one drug and titrate 1, 3

First-Line Monotherapy Options

Choose from three first-line drug classes: thiazide/thiazide-like diuretics, ACE inhibitors/ARBs, or calcium channel blockers. 1, 3

Specific Drug Selection Based on Patient Characteristics:

For patients with chronic kidney disease or diabetes with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g): ACE inhibitor or ARB is strongly recommended 1, 2

For patients with coronary artery disease: ACE inhibitor or ARB is recommended 1

For patients with heart failure with reduced ejection fraction: ACE inhibitor or ARB is recommended 2

For Black patients: Calcium channel blocker or thiazide diuretic is preferred over ACE inhibitor/ARB as initial monotherapy 4

For non-Black patients without compelling indications: Any of the three first-line classes is acceptable 4, 3

Dual Therapy (Second Agent)

When blood pressure remains uncontrolled on monotherapy at optimal dose, add a second agent from a different class. 1, 2

Preferred Two-Drug Combinations:

• ACE inhibitor/ARB + calcium channel blocker 4, 2
• ACE inhibitor/ARB + thiazide diuretic 2
• Calcium channel blocker + thiazide diuretic (particularly effective for Black patients) 4

For patients already on amlodipine, add either an ACE inhibitor/ARB or a thiazide-like diuretic. 4

• The combination of amlodipine with an ACE inhibitor demonstrates superior blood pressure control and may attenuate peripheral edema associated with amlodipine 4
• Chlorthalidone 12.5-25mg daily is preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes 1, 4

Triple Therapy (Third Agent)

When blood pressure remains uncontrolled on dual therapy at optimal doses, add a third agent to achieve the guideline-recommended combination: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic. 1, 4, 2

• This combination targets three complementary mechanisms: renin-angiotensin system blockade, vasodilation, and volume reduction 4
• Optimize doses of existing medications before adding the third agent 4, 5
• Single-pill combinations are strongly preferred to improve adherence 4

Resistant Hypertension (Fourth Agent)

If blood pressure remains ≥130/80 mmHg despite three-drug therapy at optimal doses, add spironolactone 25-50mg daily as the preferred fourth-line agent. 1, 4, 2

• Spironolactone provides additional blood pressure reductions of 20-25/10-12 mmHg when added to triple therapy 4
• Monitor serum potassium closely when combining spironolactone with ACE inhibitor/ARB due to hyperkalemia risk 1, 4
• Alternative fourth-line agents if spironolactone is contraindicated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 4, 5

Monitoring and Follow-Up

Reassess blood pressure within 2-4 weeks after initiating or adjusting therapy, with the goal of achieving target blood pressure within 3 months. 4, 2, 5

• Once controlled, follow-up every 3-6 months 2
• Monitor serum potassium and creatinine 2-4 weeks after initiating ACE inhibitor/ARB or diuretic therapy 4
• Check for medication adherence before escalating therapy, as non-adherence is the most common cause of apparent treatment resistance 4, 2, 5

Critical Pitfalls to Avoid

Never combine an ACE inhibitor with an ARB—this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit. 1, 4, 2

Do not add a beta-blocker as third-line therapy unless there are compelling indications (angina, post-myocardial infarction, heart failure with reduced ejection fraction, or need for heart rate control) 4

Do not add a third drug class before maximizing doses of the current two-drug regimen—this violates guideline-recommended stepwise approaches and may expose patients to unnecessary polypharmacy 4

Do not use non-dihydropyridine calcium channel blockers (diltiazem or verapamil) in patients with left ventricular dysfunction or heart failure due to negative inotropic effects 4

Always rule out secondary causes of hypertension (primary aldosteronism, renal artery stenosis, obstructive sleep apnea, medication interference) if blood pressure remains severely elevated or resistant to treatment 4, 2, 6

Verify medication adherence and confirm proper blood pressure measurement technique before assuming treatment failure 4, 2, 5

Special Populations

For elderly patients (≥65 years): Target systolic blood pressure <130 mmHg, but individualize based on frailty 2, 5

For patients with diabetes: Target <130/80 mmHg, with ACE inhibitor or ARB strongly recommended if albuminuria is present 1

For Black patients: Calcium channel blocker + thiazide diuretic combination may be more effective than calcium channel blocker + ACE inhibitor/ARB 4

Referral Indications

Refer to a hypertension specialist if blood pressure remains uncontrolled (≥160/100 mmHg) despite four-drug therapy at optimal doses, or if concerning features suggesting secondary hypertension are identified. 1, 4, 5