What is the recommended treatment for a patient with hypertension?

Recommended Treatment for Hypertension

For most adults with confirmed hypertension, treatment should begin with combination therapy using an ACE inhibitor or ARB plus either a calcium channel blocker or thiazide-like diuretic, targeting a blood pressure of <130/80 mmHg (or <140/90 mmHg minimum), alongside lifestyle modifications including sodium restriction to <2.3g/day, weight management, regular exercise, and alcohol limitation. 1, 2

Initial Pharmacological Approach

First-Line Medication Classes

• ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and thiazide/thiazide-like diuretics are the recommended first-line agents for hypertension treatment 1, 2, 3
• Chlorthalidone and indapamide are preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes data 1, 4

Starting Strategy Based on Blood Pressure Level

• For BP ≥140/90 mmHg: Start with dual combination therapy (RAS blocker + calcium channel blocker OR RAS blocker + thiazide diuretic), preferably as a single-pill combination to improve adherence 1, 2
• For BP ≥160/100 mmHg: Initiate two drugs immediately or a single-pill combination of drugs demonstrated to reduce cardiovascular events 1
• For BP 120-139/80-89 mmHg: Begin with lifestyle modifications; add pharmacotherapy if high cardiovascular risk or diabetes is present 1

Preferred Combination Regimens

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker provides complementary vasodilation and renin-angiotensin system blockade 4, 2
• RAS blocker + thiazide-like diuretic is particularly effective for volume-dependent hypertension and elderly patients 4, 2
• Single-pill combinations are strongly preferred over separate pills to enhance adherence 1, 2

Lifestyle Modifications (Essential for All Patients)

Dietary Interventions

• Sodium restriction to <2.3g (100 mEq) per day produces 5-10 mmHg systolic reduction 1, 2, 5, 3
• DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy, polyunsaturated fats) reduces BP by 11.4/5.5 mmHg 2, 5
• Potassium supplementation through dietary sources (8-10 servings of fruits/vegetables daily) 1

Weight and Exercise

• Weight loss: 10 kg reduction produces 6.0/4.6 mmHg decrease; target BMI 20-25 kg/m² 2
• Regular aerobic exercise: Minimum 150 minutes moderate-intensity or 75 minutes vigorous-intensity weekly, plus resistance training 2-3 times/week 2, 3

Alcohol and Tobacco

• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women (or <14 units/week for men, <8 units/week for women) 1, 2
• Complete tobacco cessation is mandatory as smoking independently causes cardiovascular disease 2

Treatment Escalation Algorithm

If BP Uncontrolled on Dual Therapy

• Add a third agent from the remaining class to create triple therapy: RAS blocker + calcium channel blocker + thiazide-like diuretic 1, 4, 2
• Optimize doses of existing medications before adding additional agents 4
• Reassess within 2-4 weeks after any medication adjustment 4, 2

Resistant Hypertension (BP ≥140/90 mmHg Despite 3 Drugs Including Diuretic)

• First, verify medication adherence (most common cause of apparent resistance) and rule out secondary causes 1, 4, 6
• Add spironolactone 25-50mg daily as the preferred fourth-line agent, with demonstrated BP reductions of 20-25/10-12 mmHg 1, 4, 2
• Monitor serum potassium and creatinine within 1-2 weeks after initiating spironolactone, especially with concurrent RAS blocker use 1, 2
• Alternative fourth-line agents if spironolactone contraindicated: eplerenone, amiloride, bisoprolol, doxazosin, or higher-dose thiazide diuretic 1

Special Population Considerations

Black Patients

• Initial therapy should include a diuretic or calcium channel blocker, either alone or combined with a RAS blocker 1, 4
• The combination of calcium channel blocker + thiazide diuretic may be more effective than calcium channel blocker + RAS blocker in this population 1, 4

Patients with Diabetes

• RAS blockers (ACE inhibitor or ARB) at maximum tolerated dose are first-line for those with urinary albumin-to-creatinine ratio ≥30 mg/g 1
• Target BP <130/80 mmHg 1
• Multiple-drug therapy is generally required; avoid combining ACE inhibitors with ARBs 1

Patients with Chronic Kidney Disease

• RAS blockers are recommended as part of treatment strategy, especially with albuminuria or proteinuria, due to superior reduction of albuminuria 1
• Target systolic BP 120-129 mmHg for eGFR >30 mL/min/1.73 m² if tolerated 1

Elderly Patients (≥65 Years)

• Target systolic BP 130-139 mmHg 1, 2
• Avoid overly aggressive diastolic lowering below 60 mmHg 2
• Individualize targets based on frailty and tolerability 1

Patients with Heart Failure

• For HFrEF: ACE inhibitor (or ARB if intolerant) or ARNI, beta-blocker, MRA, and SGLT2 inhibitors are recommended 1
• For HFpEF: SGLT2 inhibitors are recommended; ARBs and/or MRAs may be considered 1

Patients with Coronary Artery Disease

• RAS blockers and beta-blockers are first-line, with or without calcium channel blockers 1
• Target BP <130/80 mmHg (<140/80 in elderly) 1

Patients with Previous Stroke

• RAS blockers, calcium channel blockers, and diuretics are first-line 1
• Target systolic BP 120-130 mmHg should be considered 1

Blood Pressure Targets

General Population

• Primary target: 120-129/70-79 mmHg if well tolerated 1, 2
• Minimum acceptable: <140/90 mmHg 1, 2
• Higher-risk patients (diabetes, CKD, established CVD): <130/80 mmHg 1, 4

Monitoring

• Home BP monitoring target: <135/85 mmHg 4, 2
• 24-hour ambulatory BP target: <130/80 mmHg 4
• Achieve target BP within 3 months of treatment initiation or modification 4, 2

Critical Pitfalls to Avoid

Medication Errors

• Never combine ACE inhibitor with ARB or use dual RAS blockade with direct renin inhibitors—increases adverse events (hyperkalemia, acute kidney injury) without cardiovascular benefit 1, 4
• Do not use beta-blockers as first-line unless compelling indications exist (angina, post-MI, HFrEF, rate control) 1, 4
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with left ventricular dysfunction or heart failure 4

Treatment Strategy Errors

• Do not delay treatment intensification in stage 2 hypertension (≥160/100 mmHg)—prompt action reduces cardiovascular risk 4
• Do not add fourth agent before optimizing triple therapy doses—violates guideline-recommended stepwise approach 4
• Do not use monotherapy in high-risk patients—combination therapy is more effective and necessary 7, 2

Monitoring Failures

• Always monitor serum creatinine/eGFR and potassium at least annually when using ACE inhibitors, ARBs, or diuretics 1
• Screen for interfering substances (NSAIDs, decongestants, oral contraceptives, corticosteroids) that elevate BP or reduce medication efficacy 2, 6
• Rule out secondary hypertension in young patients, those with resistant hypertension, or sudden onset/worsening (consider primary aldosteronism, renal artery stenosis, obstructive sleep apnea, pheochromocytoma) 4, 2, 6

Monitoring and Follow-Up

• Check BP within 4 weeks of any medication adjustment 2
• Confirm diagnosis with home BP monitoring or 24-hour ambulatory monitoring if white coat hypertension suspected 4
• Assess medication adherence at every visit—nonadherence affects 10-80% of hypertensive patients 2
• Monitor for adverse effects: cough with ACE inhibitors, peripheral edema with calcium channel blockers (attenuated by adding RAS blocker), hyperkalemia with RAS blockers/MRAs, hypokalemia with thiazides 4