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

Blood Pressure Treatment Thresholds

For patients with diabetes or cardiovascular disease, start pharmacologic therapy immediately at blood pressure ≥140/90 mmHg alongside lifestyle modifications—do not delay treatment for a trial of lifestyle changes alone. 1

• For blood pressure ≥160/100 mmHg, initiate two drugs simultaneously or use a single-pill combination regardless of comorbidities 1
• For blood pressure between 130/80 mmHg and 150/90 mmHg without high-risk conditions, begin with a single antihypertensive agent 2
• For blood pressure ≥150/90 mmHg, initiate treatment with two antihypertensive medications from different classes 2

Target Blood Pressure Goals

Target <130/80 mmHg for patients with diabetes, cardiovascular disease, or chronic kidney disease. 1, 2

• The European Society of Cardiology recommends a systolic target of 120-129 mmHg for most adults when treatment is well tolerated 2
• More aggressive targets reduce cardiovascular events in high-risk populations 1

First-Line Pharmacologic Therapy Selection

For Patients with Diabetes and Albuminuria

Use ACE inhibitors or ARBs as first-line therapy at maximum tolerated dose. 1

For Patients with Diabetes Without Albuminuria

Choose from ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers 1

For Patients with Established Cardiovascular Disease

Prefer ACE inhibitors or ARBs as first-line therapy, as these agents provide additional cardiovascular protection beyond blood pressure lowering. 1

For Patients Without Specific Comorbidities

• Non-Black patients: Start with ACE inhibitor or ARB 2
• Black patients: Use ARB plus dihydropyridine calcium channel blocker, or calcium channel blocker plus thiazide-like diuretic (due to reduced response to ACE inhibitors as monotherapy) 2

Preferred Drug Combinations

For two-drug initiation, use a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide-like diuretic, preferably as a single-pill combination. 2

• Chlorthalidone is preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcome data 2
• Single-pill combinations improve medication adherence 2

Mandatory Pre-Treatment and Monitoring Requirements

Baseline Laboratory Testing

Check serum creatinine/eGFR and potassium before starting ACE inhibitors, ARBs, or diuretics. 1

Follow-Up Laboratory Testing

Recheck serum creatinine/eGFR, sodium, and potassium 7-14 days after initiation or dose changes of ACE inhibitors, ARBs, or diuretics. 1, 2

• Monitor for hyperkalemia or acute kidney injury when using ACE inhibitors or ARBs 2
• Monitor for hypokalemia when using diuretics 2
• Monitor potassium closely when adding mineralocorticoid receptor antagonist to ACE inhibitor/ARB regimen 1

Blood Pressure Monitoring Schedule

Reassess blood pressure monthly after initiation or medication changes until target achieved. 1

• Once controlled, follow up every 3-6 months 1
• Achieve blood pressure control within 3 months of treatment initiation 2

Lifestyle Modifications (Implement Simultaneously with Medications)

All patients with blood pressure >120/80 mmHg should implement comprehensive lifestyle changes alongside pharmacotherapy. 1, 2

Weight Management

Reduce excess body weight through caloric restriction for all overweight patients, as weight loss enhances antihypertensive medication effectiveness 1, 2

Dietary Interventions

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

Physical Activity

At least 150 minutes of moderate-intensity aerobic activity per week 2

Alcohol Moderation

≤2 drinks/day for men, ≤1 drink/day for women 2

Smoking Cessation

Mandatory for all patients 2

Medication Titration Strategy

Increase ACE inhibitor to full dose before adding a second agent. 2

• For lisinopril, titrate from 10 mg to 20-40 mg daily (usual dosage range 20-40 mg per day) 2
• If blood pressure remains uncontrolled on single-agent therapy, add a second agent from a different class 2

Resistant Hypertension Management

Resistant hypertension is defined as blood pressure ≥140/90 mmHg despite appropriate lifestyle management plus three drugs (diuretic + two other classes at adequate doses). 1

Standard Three-Drug Combination

ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic 1, 2

Fourth-Line Agent

Add mineralocorticoid receptor antagonist (spironolactone 25 mg daily) when blood pressure remains uncontrolled on three-drug regimen. 1, 2

• Beta-blockers and alpha-blockers are fourth- or fifth-line agents used only when spironolactone is not tolerated or contraindicated 2

Critical Contraindications and Precautions

Absolute Contraindications

ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are absolutely contraindicated in pregnancy or women planning pregnancy due to fetal injury and death. 2, 3

Specific Avoidance Situations

• Avoid ACE inhibitors in patients with history of angioedema 2
• Avoid ACE inhibitors/ARBs in patients with severe bilateral renal artery stenosis due to acute renal failure risk 2
• Use thiazides cautiously in patients with gout or history of acute gout, unless on uric acid-lowering therapy 2

Drug Combination to Avoid

Do not combine ACE inhibitors with ARBs, as this increases adverse events without added cardiovascular benefit. 2

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for lifestyle modification trial in patients with blood pressure ≥140/90 mmHg with diabetes or cardiovascular disease 1, 2
• Do not use hydrochlorothiazide when chlorthalidone or indapamide are available (longer-acting thiazide-like diuretics are preferred) 2
• Do not use beta-blockers as initial therapy unless a specific indication exists (such as heart failure or coronary disease) 2
• Do not fail to obtain prompt laboratory follow-up within 7-14 days when starting ACE inhibitors or ARBs to assess for hyperkalemia or acute kidney injury 2