What is the management plan for an adult patient with a history of cardiovascular disease (CVD) and hypertension?

Management of Hypertension in Adults with Cardiovascular Disease

For an adult patient with established cardiovascular disease and hypertension, initiate combination antihypertensive therapy immediately with a RAS blocker (ACE inhibitor or ARB) plus a dihydropyridine calcium channel blocker, targeting a systolic blood pressure of 120-129 mmHg. 1

Immediate Treatment Initiation

• Start pharmacological treatment promptly for any patient with confirmed BP ≥140/90 mmHg who has established CVD, regardless of additional risk stratification. 1
• The presence of CVD automatically places this patient in the high-risk category, eliminating the need for 10-year ASCVD risk calculation. 1
• Do not delay treatment with lifestyle modifications alone—both lifestyle measures AND pharmacological therapy must be initiated simultaneously. 1

First-Line Pharmacological Regimen

Combination therapy is mandatory as initial treatment:

• Preferred combination: ACE inhibitor (e.g., lisinopril 10 mg daily) OR ARB (e.g., losartan 50 mg daily) PLUS dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily). 1, 2
• Use a fixed-dose single-pill combination whenever possible to improve adherence. 1, 2
• These drug classes (ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics) have demonstrated the most effective reduction in both BP and cardiovascular events. 1

Special considerations for patients with CVD:

• If the patient has stable ischemic heart disease with angina, ACE inhibitors or ARBs combined with beta-blockers are recommended as first-line therapy. 1
• If the patient had a myocardial infarction within the past 3 years, beta-blockers should be included in the regimen. 1
• If the patient has heart failure with reduced ejection fraction, prioritize ACE inhibitors or ARBs with beta-blockers. 1

Blood Pressure Target

• Target systolic BP: 120-129 mmHg for most adults with CVD, provided treatment is well tolerated. 1, 2
• This lower target (compared to the older 140/90 mmHg goal) is based on evidence showing continuing reduction in cardiovascular events at progressively lower systolic BP levels. 1
• If the patient cannot tolerate achieving 120-129 mmHg due to adverse effects, apply the ALARA principle: target a systolic BP level that is "as low as reasonably achievable." 1, 2

Important caveat regarding diastolic BP:

• Exercise caution if diastolic BP falls below 60 mmHg, particularly in patients with coronary artery disease, as coronary perfusion occurs predominantly during diastole. 3
• However, do not withhold systolic BP lowering even if it further reduces diastolic pressure—the benefit of lowering systolic BP outweighs this concern. 3

Treatment Escalation Algorithm

If BP is not controlled with the initial two-drug combination:

• Escalate to a three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide). 1, 2
• Continue using single-pill combinations when possible. 1
• Reassess BP within 2-4 weeks after initiating or adjusting therapy. 1, 4
• Monitor serum creatinine, eGFR, and potassium levels 2-4 weeks after starting RAS blockers or diuretics. 1, 5

For resistant hypertension (BP not controlled on three drugs):

• Consider referral to a hypertension specialist. 1
• Screen for secondary causes of hypertension, including primary aldosteronism (measure renin and aldosterone). 1

Essential Lifestyle Modifications

These must be implemented concurrently with pharmacological therapy:

• Smoking cessation: Refer to smoking cessation programs immediately—tobacco use independently causes CVD and mortality. 1, 2, 4
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women). 2
• Dietary modifications: Adopt Mediterranean or DASH diet patterns. 2
• Sodium restriction: Limit intake to <2 g/day (approximately 5 g salt/day). 1, 5
• Potassium supplementation: Increase intake by 0.5-1.0 g/day through potassium-enriched salt (75% sodium chloride/25% potassium chloride) or fruits and vegetables—but monitor potassium levels closely when using ACE inhibitors, ARBs, or diuretics. 1, 5
• Sugar restriction: Limit free sugar to maximum 10% of energy intake; eliminate sugar-sweetened beverages. 1, 2, 5
• Alcohol limitation: Preferably avoid completely. 2
• Physical activity: Engage in regular aerobic and resistance training. 2

Monitoring and Long-Term Management

• Initial monitoring: Reassess BP, adherence, and tolerance within 2-4 weeks of starting or adjusting therapy. 1, 4
• Once controlled: Follow up at least yearly for BP and other cardiovascular risk factors. 1, 5
• Lifelong treatment: Maintain BP-lowering medication indefinitely, even beyond age 85 years, if well tolerated. 1, 2, 4
• Consider home BP monitoring to improve control and patient engagement. 2
• Use multidisciplinary approaches involving physicians, nurses, pharmacists, and dietitians. 2

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB)—this increases adverse effects without additional benefit. 1, 2, 4
• Do not use monotherapy in patients with confirmed hypertension ≥140/90 mmHg—combination therapy is more effective. 1, 2
• Do not delay pharmacological treatment in favor of lifestyle modifications alone in patients with established CVD. 1
• Do not use beta-blockers as first-line therapy unless there are compelling indications (recent MI, angina, heart failure, or heart rate control). 1, 2, 4
• Do not discontinue treatment prematurely—BP control requires lifelong medication. 1, 4
• Do not ignore orthostatic hypotension—test for it before starting or intensifying treatment, especially in older patients. 1, 2

Medication Timing and Adherence

• Instruct the patient to take medications at the most convenient time of day to establish a habitual pattern and improve adherence. 1, 2, 4
• Address all five dimensions of adherence: socioeconomic factors, health system factors, therapy-related factors, condition-related factors, and patient-related factors. 2