What is the appropriate management for a patient with stage 2 hypertension, ECG changes, and relatively preserved kidney function with an estimated GFR of 82 ml/min/1.73m^2?

Management of Stage 2 Hypertension with ECG Changes and eGFR 82 mL/min/1.73m²

This patient requires immediate initiation of antihypertensive medication, specifically an ACE inhibitor or ARB as first-line therapy, combined with a thiazide-type diuretic, with a target blood pressure of <130/80 mm Hg. 1

Classification and Risk Stratification

Your patient has:

• Stage 2 hypertension (BP ≥140/90 mm Hg) 1
• CKD Stage 2 (eGFR 60-89 mL/min/1.73m² with kidney damage evidenced by ECG changes suggesting left ventricular hypertrophy) 1
• High cardiovascular risk warranting immediate pharmacologic intervention 1

The presence of ECG changes (likely left ventricular hypertrophy) in the context of stage 2 hypertension places this patient in a category requiring aggressive treatment regardless of 10-year ASCVD risk calculation. 1

First-Line Antihypertensive Therapy

ACE Inhibitor or ARB as Foundation

Start lisinopril 10 mg once daily (or equivalent ARB if ACE inhibitor not tolerated). 2, 3

• ACE inhibitors/ARBs are specifically recommended as first-line agents in hypertensive patients with CKD, even with preserved kidney function (eGFR >60 mL/min/1.73m²). 1
• No dose adjustment is required for lisinopril when eGFR >30 mL/min/1.73m². 2
• The presence of ECG changes (presumed LVH) makes renin-angiotensin system blockade particularly important for cardiovascular protection. 1

Add Thiazide-Type Diuretic

Add chlorthalidone 12.5-25 mg once daily (preferred over hydrochlorothiazide). 4, 3

• Thiazide diuretics are explicitly recommended as first-line agents across all CKD stages, including Stage 2. 4
• Chlorthalidone is superior to hydrochlorothiazide due to longer half-life and better blood pressure control in major trials. 4
• The combination of ACE inhibitor plus thiazide produces approximately additive blood pressure lowering effects. 2, 3
• At eGFR 82 mL/min/1.73m², thiazides remain fully effective without hesitation. 4

Why Not Calcium Channel Blockers First?

While calcium channel blockers (amlodipine) are also first-line agents 3, the presence of ECG changes and CKD makes ACE inhibitor/ARB + thiazide the preferred initial combination for this specific patient due to superior cardiovascular and renal protection. 1, 4

Consider SGLT2 Inhibitor for Cardiovascular/Renal Protection

Add dapagliflozin 10 mg once daily for additional cardiovascular and renal protection, independent of diabetes status. 5, 6

• SGLT2 inhibitors reduce cardiovascular death or heart failure hospitalization by 26-29% and kidney disease progression by 39-44%. 5, 6
• Dapagliflozin can be initiated at eGFR ≥25 mL/min/1.73m² for cardiovascular/renal protection. 5
• The presence of ECG changes (likely LVH) indicates established cardiovascular involvement, making SGLT2 inhibitor use particularly appropriate. 5, 6
• This is recommended regardless of diabetes status for patients with hypertension and cardiovascular changes. 5, 6

Blood Pressure Target

Target BP <130/80 mm Hg in this patient under age 65. 1, 3

• For adults <65 years, the target is SBP/DBP <130/80 mm Hg. 3
• Each 10 mm Hg reduction in SBP decreases cardiovascular events by 20-30%. 3

Monitoring Protocol

Initial Monitoring (First 2-4 Weeks)

• Recheck electrolytes (sodium, potassium) and renal function within 2-4 weeks of starting ACE inhibitor and thiazide. 4, 2
• Expect a small, transient eGFR dip of 3-5 mL/min/1.73m² if SGLT2 inhibitor added—this is hemodynamic and protective, not harmful. 5
• Monitor for orthostatic hypotension, particularly in the first week. 2

Ongoing Monitoring

• Assess eGFR and albuminuria at least annually in CKD Stage 2. 1
• Check blood pressure at every clinic visit (at least every 3 months). 1
• Repeat ECG in 6-12 months to assess for regression of left ventricular hypertrophy with treatment. 1

Critical Pitfalls to Avoid

Do Not Combine ACE Inhibitor with ARB

Never use ACE inhibitor + ARB combination—this increases adverse events without additional benefit. 1, 4

Do Not Withhold Thiazides Due to "Preserved" Kidney Function

The outdated belief that thiazides are ineffective in CKD is explicitly refuted by current guidelines. 4 Thiazides work effectively at eGFR 82 mL/min/1.73m² and should not be withheld. 4

Do Not Delay SGLT2 Inhibitor Until Diabetes Develops

SGLT2 inhibitors provide cardiovascular and renal protection independent of diabetes status. 5, 6 Waiting for diabetes to develop before initiating this medication misses a critical window for cardiovascular protection in a patient with established ECG changes. 5, 6

Monitor for Hyponatremia with Thiazides

Elderly patients have heightened risk of hyponatremia with thiazide diuretics, requiring closer surveillance. 4 Check sodium within 2-4 weeks of initiation. 4

Lifestyle Modifications (Adjunctive)

• Dietary sodium restriction to <3.3 g/day (not the overly restrictive <2 g/day). 1
• Weight loss if BMI elevated. 3
• Physical activity and alcohol moderation. 3
• These lifestyle changes are partially additive to medication effects. 3

When to Refer to Nephrology

Referral is not yet indicated at eGFR 82 mL/min/1.73m². 1

• Nephrology referral is recommended when eGFR <30 mL/min/1.73m². 1
• However, if albuminuria develops with UACR >60 mg/mmol (approximately >530 mg/g) or proteinuria >1 g/day, earlier referral is warranted. 1