What are the guidelines for managing hypertension in primary care, particularly for patients with a history of cardiovascular disease or diabetes?

Hypertension Management in Primary Care

For patients with hypertension in primary care, particularly those with cardiovascular disease or diabetes, initiate both lifestyle modifications and pharmacologic therapy simultaneously when blood pressure is ≥140/90 mmHg, using ACE inhibitors or ARBs as first-line agents for those with diabetes and albuminuria, and thiazide-like diuretics, ACE inhibitors/ARBs, or calcium channel blockers for others. 1

Blood Pressure Thresholds for Treatment Initiation

Patients with Diabetes or Cardiovascular Disease

• Start pharmacologic therapy immediately at blood pressure ≥140/90 mmHg alongside lifestyle modifications 1
• For blood pressure ≥160/100 mmHg, initiate two drugs simultaneously or use a single-pill combination 1
• Do not delay treatment for a trial of lifestyle modification alone when blood pressure is ≥140/90 mmHg 2

Blood Pressure 120-139/80-89 mmHg

• Implement intensive lifestyle interventions for all patients in this range 1
• Consider pharmacologic therapy if 10-year cardiovascular disease risk is ≥20% despite lifestyle measures 1

First-Line Pharmacologic Therapy

Patients with Diabetes and Albuminuria

• Use ACE inhibitor or ARB at maximum tolerated dose as first-line therapy 1
• Specifically indicated for urinary albumin-to-creatinine ratio ≥300 mg/g (macroalbuminuria) or 30-299 mg/g (microalbuminuria) 1
• If one class is not tolerated, substitute the other 1

Patients with Diabetes Without Albuminuria

• Choose from ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers 1
• All four classes have demonstrated cardiovascular event reduction in patients with diabetes 1

Patients with Established Cardiovascular Disease

• Prefer ACE inhibitors or ARBs as first-line therapy 2
• These agents provide additional cardiovascular protection beyond blood pressure lowering 2

General Hypertensive Patients

• Use thiazide-like diuretics (chlorthalidone or indapamide preferred over hydrochlorothiazide), ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers 1, 3
• Long-acting thiazide-like diuretics are superior to hydrochlorothiazide for cardiovascular outcomes 2

Combination Therapy Strategy

When to Start Two Medications

• Blood pressure ≥160/100 mmHg requires immediate initiation of two drugs or single-pill combination 1
• Blood pressure >20/10 mmHg above target warrants two-drug initiation 1

Preferred Two-Drug Combinations

• ACE inhibitor or ARB + thiazide-like diuretic 1, 2
• ACE inhibitor or ARB + dihydropyridine calcium channel blocker 1, 2
• Dihydropyridine calcium channel blocker + thiazide-like diuretic 2
• Single-pill combinations are preferred to improve adherence 2

Prohibited Combinations

• Never combine ACE inhibitors with ARBs - this increases adverse events without cardiovascular benefit 1, 2
• Never combine ACE inhibitors or ARBs with direct renin inhibitors 1

Blood Pressure Targets

Patients with Diabetes

• Target <130/80 mmHg 1
• More aggressive targets reduce cardiovascular events in this population 1

Patients with Cardiovascular Disease or Chronic Kidney Disease

• Target <130/80 mmHg 1, 2
• Lower targets are supported by intervention trial evidence 1

General Adult Population

• Target <140/90 mmHg as minimum acceptable standard 1
• Optimal target is <130/80 mmHg for most adults under 65 years 2, 3
• For adults ≥65 years, target systolic <130 mmHg if tolerated 3

Lifestyle Modifications (All Patients)

Weight Management

• Reduce excess body weight through caloric restriction for all overweight patients with blood pressure >120/80 mmHg 1
• Weight loss enhances antihypertensive medication effectiveness 1

Dietary Interventions

• DASH diet pattern: 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products daily 1, 2
• Restrict sodium intake to <2,300 mg/day 1, 2
• Increase potassium intake through dietary sources 1, 2

Alcohol and Physical Activity

• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• Increase physical activity levels - at least 150 minutes of moderate-intensity aerobic activity weekly 1, 2

Monitoring Requirements

Laboratory Monitoring

• Check serum creatinine/eGFR and potassium at baseline before starting ACE inhibitors, ARBs, or diuretics 2
• Recheck these values 7-14 days after initiation or dose changes 2
• Monitor at least annually thereafter 1

Blood Pressure Follow-Up

• Reassess blood pressure monthly after initiation or medication changes until target achieved 4
• Once controlled, follow up every 3-6 months 2

Resistant Hypertension Management

Definition and Evaluation

• Blood pressure ≥140/90 mmHg despite appropriate lifestyle management plus three drugs (diuretic + two other classes at adequate doses) 1
• Before diagnosing resistant hypertension, exclude medication nonadherence, white coat hypertension, and secondary causes 1
• Address barriers to adherence including cost and side effects 1

Treatment Approach

• Add mineralocorticoid receptor antagonist (spironolactone) when blood pressure remains uncontrolled on three-drug regimen 1, 2
• Standard three-drug combination: ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic 2
• Monitor potassium closely when adding mineralocorticoid receptor antagonist to ACE inhibitor/ARB regimen 1

Critical Pitfalls to Avoid

Medication Selection Errors

• Do not use beta-blockers as first-line therapy unless specific cardiac indication exists (heart failure, coronary disease) 4
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available 2
• Do not underdose medications before adding additional agents - titrate to maximum tolerated dose first 4

Monitoring Failures

• Failure to check potassium and creatinine within 7-14 days of starting ACE inhibitors/ARBs can miss dangerous hyperkalemia or acute kidney injury 2
• Do not delay laboratory follow-up beyond 2 weeks 2

Treatment Delays

• Do not delay pharmacotherapy for 3-6 months of lifestyle modification trial when blood pressure is ≥140/90 mmHg 2
• Simultaneous initiation of lifestyle and pharmacologic therapy is the standard approach 1, 2