What is the recommended management approach for a patient with hypertension?

Hypertension Management

Confirm the Diagnosis First

Before initiating treatment, confirm hypertension using out-of-office measurements—either home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (daytime mean ≥130/80 mmHg)—to avoid treating white coat hypertension. 1

• Office BP 140-159/90-99 mmHg requires confirmation within a reasonable timeframe via home or ambulatory monitoring 1
• Office BP ≥160/100 mmHg should be confirmed as soon as possible, preferably within 1 month 1
• Office BP ≥180/110 mmHg requires immediate evaluation to exclude hypertensive emergency 1

Essential Baseline Workup

Obtain these tests before starting treatment to guide therapy and identify secondary causes: 1

• Serum creatinine and eGFR
• Urine albumin-to-creatinine ratio (ACR)
• Blood glucose and lipid profile
• Electrolytes (sodium, potassium)
• 12-lead ECG 1
• Echocardiography if ECG abnormalities or cardiac symptoms present 1
• Screen for secondary hypertension if: age <30 years requiring treatment, resistant hypertension (≥3 drugs), sudden onset/worsening, or suggestive clinical features 1

Blood Pressure Targets

Target systolic BP of 120-129 mmHg and diastolic <80 mmHg for most adults when treatment is well tolerated. 1, 2

• For patients with diabetes, CKD, or established CVD: target <130/80 mmHg 1, 2
• For adults ≥65 years: target systolic <130 mmHg 1

Initiate Both Lifestyle Modifications AND Medications Simultaneously

Do not delay pharmacotherapy for a trial of lifestyle changes alone—the European Society of Cardiology recommends starting both interventions together for all patients with confirmed hypertension. 1, 2

When to Start Pharmacotherapy:

• Immediate treatment: BP ≥140/90 mmHg regardless of cardiovascular risk 1, 2
• Immediate treatment: BP 130-139/80-89 mmHg with high CVD risk (≥10% 10-year risk, diabetes, CKD, or established CVD) 1

Lifestyle Modifications (Implement Alongside Medications):

• Sodium restriction: <2 g/day (equivalent to ~5 g salt/day) reduces SBP by 5-8 mmHg 1
• DASH or Mediterranean diet: 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy, whole grains, reduced saturated fat 1, 2
• Weight loss: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women); approximately 1 mmHg SBP reduction per 1 kg weight loss 1, 2
• Exercise: Minimum 150 minutes/week of moderate-intensity aerobic exercise plus resistance training 2-3 times/week reduces SBP by 4-9 mmHg 1, 2, 3
• Alcohol restriction: Limit to <100 g/week of pure alcohol (≤2 drinks/day for men, ≤1 drink/day for women) 1, 2
• Complete tobacco cessation with referral to cessation programs 1
• Potassium supplementation through dietary sources (fruits/vegetables) unless contraindicated by CKD 1

Initial Pharmacological Therapy

Most patients should start with two-drug combination therapy, preferably as a single-pill combination to improve adherence. 1, 2

Preferred Initial Combinations for Non-Black Patients:

• ACE inhibitor or ARB + dihydropyridine calcium channel blocker (DHP-CCB) 1, 2
• ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1, 2

For Black Patients:

• ARB + dihydropyridine calcium channel blocker 1
• Calcium channel blocker + thiazide/thiazide-like diuretic 1
• Avoid ACE inhibitors as monotherapy due to reduced response 1

Specific Drug Options:

• Thiazide-like diuretics: Chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 3
• ACE inhibitors: Lisinopril 10-20 mg daily or enalapril 3
• ARBs: Losartan or candesartan 4, 3
• Calcium channel blockers: Amlodipine 5 mg daily 3

Special Population Considerations

Diabetes:

• ACE inhibitor or ARB is mandatory as first-line therapy to reduce progression of diabetic nephropathy 1
• Target BP <130/80 mmHg 1

Chronic Kidney Disease (CKD):

• ACE inhibitor or ARB for patients with albuminuria (UACR ≥30 mg/g) to reduce progressive kidney disease 1
• Target BP <130/80 mmHg 1

Coronary Artery Disease:

• ACE inhibitor or ARB as first-line therapy 1
• Beta-blockers indicated if history of myocardial infarction or heart failure 1

Heart Failure:

• Combination of ACE inhibitor/ARB, beta-blocker, diuretic, and mineralocorticoid receptor antagonist per heart failure guidelines 1

Pregnancy or Planning Pregnancy:

• Absolute contraindications: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors (aliskiren), neprilysin inhibitors (cause fetal injury/death) 1, 5
• Preferred agents: Methyldopa, nifedipine, or labetalol 1

Titration and Follow-Up Strategy

Achieve BP control within 3 months with monthly follow-up visits until target is reached. 1

• Recheck BP in 1 month after any medication change 1
• Monitor serum creatinine, eGFR, sodium, and potassium within 7-14 days after initiating or changing ACE inhibitors, ARBs, or diuretics 1
• If BP not controlled with two drugs, escalate to three-drug combination (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1
• If BP not controlled with three drugs, add spironolactone 25 mg daily 1

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for a trial of lifestyle modifications alone in patients with BP ≥140/90 mmHg 1
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics are preferred 1
• Avoid beta-blockers as initial therapy unless a specific indication exists (heart failure, coronary disease, post-MI) 1
• Do not combine ACE inhibitors with ARBs, as this increases adverse events without added cardiovascular benefit 6
• Confirm elevated readings with multiple measurements before diagnosis to avoid treating white coat hypertension 2
• Monitor for hyperkalemia or acute kidney injury within 7-14 days when starting ACE inhibitors or ARBs 6