What is the management approach for hypertension in adult patients?

Management of Hypertension in Adults

For adults with hypertension, initiate pharmacologic treatment at BP ≥130/80 mmHg if 10-year ASCVD risk is ≥10% or if cardiovascular disease/chronic kidney disease is present, targeting BP <130/80 mmHg, using combination therapy with two first-line agents (ACE inhibitor or ARB plus either a calcium channel blocker or thiazide/thiazide-like diuretic) as initial treatment for most patients. 1, 2, 3

Diagnostic Confirmation

• Confirm the diagnosis with accurate office BP measurements using standardized technique, and obtain home or ambulatory BP monitoring to exclude white coat hypertension before initiating treatment 1, 2
• Screen for secondary causes of hypertension in all adults diagnosed before age 40 (except obese young adults, where obstructive sleep apnea should be evaluated first) 1
• Evaluate for hypertension-mediated organ damage (heart, kidneys, blood vessels, eyes) to identify additional high-risk individuals 1

Blood Pressure Targets

• Target BP <130/80 mmHg for most adults with confirmed hypertension and known CVD or 10-year ASCVD risk ≥10% 2, 4
• For noninstitutionalized, ambulatory, community-dwelling adults ≥65 years with average SBP ≥130 mmHg, target SBP <130 mmHg 5, 2
• The most recent European guidelines recommend an even more aggressive target of 120-129/<80 mmHg for most adults if well tolerated 1
• If target cannot be achieved due to poor tolerance, aim for "as low as reasonably achievable" (ALARA principle) 1

Initial Pharmacologic Treatment

First-Line Medication Combinations

• Initiate two-drug combination therapy as initial treatment for most patients, preferably as a single-pill combination 1, 3
• Preferred combinations include:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker (preferably amlodipine) 1, 3
  • RAS blocker + thiazide/thiazide-like diuretic (preferably chlorthalidone or indapamide over hydrochlorothiazide) 1, 3
  • Calcium channel blocker + thiazide/thiazide-like diuretic 1, 3

Specific First-Line Agents

• ACE inhibitors (e.g., lisinopril, enalapril): Indicated for hypertension treatment, reduce cardiovascular events, and are particularly beneficial in patients with diabetes, chronic kidney disease, heart failure, or post-myocardial infarction 6, 4
• ARBs (e.g., losartan, candesartan): Indicated for hypertension, reduce stroke risk in patients with left ventricular hypertrophy (though this benefit may not apply to Black patients), and treat diabetic nephropathy 7, 4
• Thiazide/thiazide-like diuretics: Chlorthalidone or indapamide preferred over hydrochlorothiazide for superior cardiovascular outcomes 1, 4
• Calcium channel blockers: Long-acting dihydropyridines like amlodipine are preferred 1, 4

Race-Specific Considerations

• In Black patients, thiazide diuretics and calcium channel blockers are preferred first-line agents, as β-blockers and RAS inhibitors are less effective at lowering BP in this population 3

Lifestyle Modifications (Concurrent with Medications)

• Weight management: Target BMI 18.5-24.9 kg/m² and waist circumference <102 cm for men, <88 cm for women 1, 4
• Dietary sodium restriction: Limit to <2300 mg (100 mmol)/day, ideally 1500-2300 mg/day in hypertensive patients 4, 8
• DASH or Mediterranean diet: Emphasize fruits, vegetables, low-fat dairy products, whole grains, dietary fiber, and plant-based protein while reducing saturated fat and cholesterol 4, 8
• Physical activity: 30-60 minutes of aerobic exercise 4-7 days per week 4, 8
• Alcohol limitation: ≤14 standard drinks/week for men, ≤9 drinks/week for women 4, 8
• Smoking cessation: Essential for comprehensive cardiovascular risk reduction 4

Treatment Escalation Strategy

• If BP remains uncontrolled on two agents, escalate to three-drug combination (RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic), preferably as single-pill combination 3
• For resistant hypertension (BP ≥130/80 mmHg on ≥3 optimal-dose agents including a diuretic):
  • Confirm true resistance with home/ambulatory BP monitoring to exclude white coat effect 5
  • Assess medication adherence (up to 25% of patients don't fill initial prescriptions) 1
  • Identify and discontinue interfering substances (NSAIDs, stimulants, oral contraceptives) 5
  • Screen for secondary causes of hypertension 5
  • Maximize diuretic therapy (switch to chlorthalidone or indapamide) 5
  • Add mineralocorticoid receptor antagonist (spironolactone or eplerenone) 5
  • Consider referral to hypertension specialist if BP remains uncontrolled 5

Follow-Up and Monitoring

• Reassess in 1 month after initiating or adjusting therapy, with monthly evaluations until BP control is achieved 3
• At each visit: measure BP using standardized technique, assess medication adherence, monitor for adverse effects, and check electrolytes and renal function 3
• Once BP is controlled and stable, follow up yearly for BP and other CVD risk factors 1
• Use once-daily dosing and combination pills to improve adherence 1, 2

Special Populations

Older Adults (≥65 Years)

• More intensive BP-lowering therapy (SBP <130 mmHg) safely reduces CVD events in those aged >65,75, and 80 years, including frail older adults living independently 5
• Initiate therapy cautiously, especially with two drugs, and monitor carefully for adverse effects including orthostatic hypotension 5
• For older adults with high comorbidity burden and limited life expectancy, use clinical judgment, patient preference, and team-based approach for treatment intensity decisions 5, 2

Patients with Diabetes Mellitus

• Target BP <130/80 mmHg 2
• ACE inhibitors or ARBs are preferred first-line agents (or thiazides/dihydropyridine CCBs in patients without albuminuria) 3, 8

Patients with Chronic Kidney Disease

• Target BP <130/80 mmHg 5, 2
• ACE inhibitors are recommended for nondiabetic CKD with proteinuria; ARBs if ACE inhibitor intolerant 5, 8
• For diabetic nephropathy with elevated creatinine and proteinuria (albumin/creatinine ratio ≥300 mg/g), losartan reduces progression to doubling of serum creatinine or end-stage renal disease 7

Patients with Cardiovascular Disease

• In patients with angina, recent MI, or heart failure: β-blockers and ACE inhibitors are first-line 8
• In patients with cerebrovascular disease: ACE inhibitor/diuretic combination is preferred 8
• For stroke risk reduction in patients with hypertension and left ventricular hypertrophy: losartan is indicated (though benefit may not apply to Black patients) 7

Critical Pitfalls to Avoid

• Do not delay treatment in stage 2 hypertension (BP ≥140/90 mmHg); prompt dual-agent therapy is required 3
• Do not start with monotherapy when BP is >20/10 mmHg above target 3
• Never combine two RAS blockers (ACE inhibitor + ARB) 1, 3
• Do not assume white coat effect without confirmation via home or ambulatory BP monitoring 3
• Do not discontinue therapy even if BP normalizes; lifelong treatment is recommended 1, 3
• In women who become pregnant, immediately discontinue ACE inhibitors, ARBs, and direct renin inhibitors; switch to methyldopa, nifedipine, or labetalol 2
• Do not rely solely on office BP measurements; home and ambulatory monitoring are essential for accurate diagnosis and management 1, 2

Implementation Strategies

• Use team-based care approach with electronic health records and patient registries to identify uncontrolled hypertension 1, 2
• Implement telehealth strategies as useful adjuncts 1, 2
• Calculate 10-year ASCVD risk to guide intensity of overall cardiovascular risk reduction strategies 3
• Consider statin therapy and aspirin in selected high-risk patients once BP is controlled 2, 8