What is the recommended treatment approach for a patient with hypertension to achieve a blood pressure goal of less than 130/80 mmHg?

Hypertension Control: Treatment Approach to Achieve BP <130/80 mmHg

To achieve a blood pressure goal of <130/80 mmHg, initiate combination therapy with an ACE inhibitor or ARB plus either a calcium channel blocker or thiazide-like diuretic, then add the third agent if needed to reach target within 3 months. 1

Initial Treatment Strategy

For Most Non-Black Patients

• Start with low-dose ACE inhibitor or ARB as the foundation 1
• Add a dihydropyridine calcium channel blocker (such as amlodipine) as the second agent 1, 2
• Increase both medications to full doses before adding a third agent 1
• Add a thiazide or thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) as the third agent if BP remains uncontrolled 1, 2, 3

For Black Patients

• Start with low-dose ARB plus dihydropyridine calcium channel blocker, or calcium channel blocker plus thiazide-like diuretic 1
• This combination is more effective than ARB plus ACE inhibitor in Black patients 1, 2
• Increase to full doses, then add the remaining drug class (diuretic or ARB/ACE inhibitor) as needed 1

Blood Pressure Targets and Monitoring

Target Goals

• Primary target: <130/80 mmHg for most patients 1, 2
• Minimum acceptable target: <140/90 mmHg 1, 3
• For elderly patients (≥65 years), individualize based on frailty, with targets ranging from <130/80 mmHg if well-tolerated to <150/90 mmHg in frail patients 4, 5

Monitoring Timeline

• Reassess BP within 2-4 weeks after any medication adjustment 1, 2
• Achieve target BP within 3 months of initiating or modifying therapy 1, 2
• Confirm hypertension diagnosis with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 1

Medication Selection and Dosing

First-Line Agents

• ACE inhibitors/ARBs: Provide renin-angiotensin system blockade, particularly beneficial for patients with diabetes, chronic kidney disease, heart failure, or coronary artery disease 2, 3, 6
• Calcium channel blockers: Amlodipine 5-10 mg daily provides vasodilation and is well-tolerated in elderly patients 2, 4, 3
• Thiazide-like diuretics: Chlorthalidone 12.5-25 mg daily is preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes 2, 3, 7

Combination Therapy Rationale

• Most patients require 2-3 medications to achieve BP <130/80 mmHg 1, 3, 7
• Combination therapy is more effective than monotherapy dose escalation for achieving target BP 7, 8
• Single-pill combinations significantly improve medication adherence and should be used when available 1, 2

Resistant Hypertension Management

Fourth-Line Agent

• If BP remains uncontrolled on triple therapy (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic), add spironolactone 25-50 mg daily as the preferred fourth-line agent 1, 2
• Alternative fourth-line agents if spironolactone is contraindicated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Before Adding Fourth Agent

• Verify medication adherence first—non-adherence is the most common cause of apparent treatment resistance 2
• Rule out secondary hypertension (primary aldosteronism, renal artery stenosis, obstructive sleep apnea, pheochromocytoma) 2, 5
• Check for interfering medications (NSAIDs, decongestants, oral contraceptives) 2
• Assess volume status, as occult volume expansion commonly underlies treatment resistance 2, 5

Lifestyle Modifications

Essential Non-Pharmacologic Interventions

• Sodium restriction to <2 g/day provides 5-10 mmHg systolic BP reduction 1, 2, 3
• Weight loss (target BMI 18.5-24.9 kg/m²) and waist circumference reduction (<102 cm for men, <88 cm for women) 3, 6
• Aerobic exercise 30-60 minutes, 4-7 days per week 3, 6
• DASH diet emphasizing fruits, vegetables, and low-fat dairy products 3, 6
• Alcohol limitation to ≤14 standard drinks/week for men, ≤9 for women 3, 6

Critical Pitfalls to Avoid

Medication Combinations

• Never combine ACE inhibitor with ARB—this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit 2, 9
• Avoid beta-blockers as second or third agent unless compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, heart rate control) 2
• Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with heart failure or left ventricular dysfunction 2

Treatment Approach Errors

• Do not add a fourth drug class before maximizing doses of the current regimen—this violates guideline-recommended stepwise approaches 2
• Do not delay treatment intensification in patients with stage 2 hypertension (≥160/100 mmHg)—start dual therapy immediately 1
• Do not withhold appropriate treatment based solely on age—base decisions on functional status and frailty, not chronological age 4, 5

Monitoring Failures

• Monitor serum potassium and creatinine 2-4 weeks after initiating ACE inhibitor/ARB or diuretic therapy 2
• Check for orthostatic hypotension in elderly patients by measuring BP in both sitting and standing positions 4, 5
• Refer to hypertension specialist if BP remains uncontrolled despite four-drug therapy at optimal doses 1, 2