What are the guidelines for managing hypertension in a patient, considering lifestyle modifications and medication therapy, including those with a history of diabetes or kidney disease?

Hypertension Management Guidelines

Blood Pressure Targets

For most adults, target blood pressure should be <130/80 mmHg, with specific targets of <130/80 mmHg for patients with diabetes or chronic kidney disease. 1

• For adults ≥65 years, target systolic blood pressure <130 mmHg 1
• The minimum acceptable target for all patients is <140/90 mmHg 2, 1
• Initial goal should be to reduce BP by at least 20/10 mmHg 1

Diagnosis and Confirmation

• Confirm hypertension using validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms and using the higher reading 1
• Office BP ≥140/90 mmHg defines hypertension, but must be confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 1
• Blood pressure should be measured at every routine visit for patients with diabetes 2
• Perform orthostatic measurements when clinically indicated, especially in elderly patients or after adjusting antihypertensive therapy 2

Lifestyle Modifications (First-Line for All Patients)

All patients with hypertension should implement comprehensive lifestyle changes, which can reduce blood pressure by 10-20 mmHg and enhance medication effectiveness. 1, 3

Dietary Interventions

• Implement DASH or Mediterranean diet pattern with 8-10 servings of fruits and vegetables daily, 2-3 servings of low-fat dairy products, and reduced saturated/trans fats 2, 1
• Restrict sodium intake to <1,500 mg/day or minimally reduce by at least 1,000 mg/day (equivalent to <2,300 mg/day) 2, 1
• Increase potassium intake to 3,500-5,000 mg/day through dietary sources 1
• Limit trans-unsaturated fatty acids to <1% of energy intake 2

Physical Activity

• Perform at least 150 minutes of moderate-intensity aerobic exercise weekly, distributed over at least 3 days per week with no more than 2 consecutive days without activity 2, 1, 3
• Add resistance training 2-3 times per week, including dynamic resistance exercise 90-150 minutes/week or isometric resistance 3 sessions/week 1
• For patients with diabetes, at least 90 minutes of vigorous aerobic exercise per week is acceptable as an alternative 2

Weight Management

• Target ideal body weight or minimum 1 kg reduction if overweight/obese (BMI goal 20-25 kg/m²) 1
• Aim for weight loss of at least 5% and preferably 10% at a rate of 1-2 lb/week over up to 6 months 2
• A 10 kg weight loss is associated with 6.0 mmHg systolic and 4.6 mmHg diastolic reduction 1

Alcohol and Smoking

• Limit alcohol to ≤2 drinks per day in men, ≤1 per day in women (one drink = 12-oz beer, 4-oz wine, or 1.5-oz distilled spirits) 2, 1
• Complete smoking cessation is recommended 2, 1

Pharmacological Treatment Algorithm

Stage 1 Hypertension (130-139/80-89 mmHg)

For patients with diabetes, chronic kidney disease, or established CVD: Start pharmacologic therapy immediately in addition to lifestyle modifications 2

For patients without high-risk conditions: Initiate lifestyle modifications for a maximum of 3 months; if BP targets not achieved, start pharmacologic therapy 2

Stage 2 Hypertension (≥140/90 mmHg)

Immediately initiate pharmacologic therapy in addition to lifestyle modifications. 2, 3

• For BP 140-159/90-99 mmHg: May begin with single-drug therapy 2
• For BP ≥160/100 mmHg: Start with two antihypertensive medications simultaneously or a single-pill combination 2, 1, 3

First-Line Medication Selection

For Non-Black Patients

The preferred initial approach is two-drug combination therapy as a single-pill combination: low-dose ACE inhibitor or ARB + dihydropyridine calcium channel blocker. 1

• First-line drug classes: thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers 2, 3
• All classes have demonstrated reduction in cardiovascular events 2, 4, 5

For Black Patients

The preferred initial regimen is low-dose ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic. 1

• Calcium channel blockers and thiazides are more effective than ACE inhibitors/ARBs as monotherapy in Black patients 1

Special Populations

Diabetes with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g): ACE inhibitor or ARB as first-line treatment 1

Chronic kidney disease: ACE inhibitor or ARB at maximum tolerated dose, especially with albuminuria 1

Heart failure: ACE inhibitor or ARB + beta-blocker + diuretic (usually loop diuretic if volume overloaded) 1

Treatment Intensification

Adding a Third Agent

If BP remains uncontrolled on two medications, add a thiazide or thiazide-like diuretic to complete the triple therapy regimen (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic). 1, 3

• Chlorthalidone is preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes 1
• Multiple-drug therapy is generally required to achieve BP targets 2

Resistant Hypertension (Uncontrolled on Three Medications)

Add spironolactone 25-50 mg daily as the preferred fourth-line agent. 2, 1

• Before adding medications, verify adherence, identify interfering medications (especially NSAIDs), and screen for secondary causes 1
• Consider referral to hypertension specialist if BP remains uncontrolled despite four-drug therapy 1

Monitoring and Follow-Up

Achieve target BP within 3 months of initiating treatment. 1

• Schedule follow-up within 2-4 weeks initially to assess response and tolerability 1
• Once controlled, recheck every 3-6 months 1
• Check serum creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Encourage home BP monitoring throughout treatment 1

Critical Pitfalls to Avoid

Never combine two RAS blockers (ACE inhibitor + ARB) as this increases adverse events including hyperkalemia and acute kidney injury without additional cardiovascular benefit. 2, 1

Avoid clinical inertia: Immediate combination therapy is more effective than sequential monotherapy titration for Stage 2 hypertension 1

Do not discontinue lifestyle modifications once drug therapy starts—they are complementary and may reduce medication requirements 1, 6

Do not add beta-blockers as third-line agents unless there are compelling indications (prior MI, heart failure with reduced ejection fraction, angina, or need for heart rate control) 1