What is the best approach to reduce high blood pressure (hypertension) in an adult patient?

Best Approach to Reduce High Blood Pressure

For most adults with confirmed hypertension (BP ≥140/90 mmHg), start combination pharmacological therapy immediately with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide-like diuretic, preferably as a single-pill combination, while simultaneously implementing lifestyle modifications targeting a systolic BP of 120-129 mmHg. 1

Initial Treatment Strategy Based on BP Level

Elevated BP (120-139/<80 mmHg) with Low CVD Risk

• Implement lifestyle modifications alone for 3 months before considering pharmacotherapy 1
• Reassess BP in 3-6 months 2

Stage 1 Hypertension (130-139/80-89 mmHg)

• Calculate 10-year ASCVD risk to guide treatment 2
• If ASCVD risk <10%: lifestyle modifications alone 1
• If ASCVD risk ≥10% or BP ≥140/90 mmHg: immediate pharmacotherapy plus lifestyle modifications 1

Stage 2 Hypertension (≥140/90 mmHg or BP >20/10 mmHg above target)

• Start dual-drug combination therapy immediately, preferably as fixed-dose single-pill combination 1
• Reassess in 1 month 2

First-Line Pharmacological Therapy

Preferred Initial Combinations

The most effective first-line regimen combines a RAS blocker (ACE inhibitor like lisinopril or ARB) with either a dihydropyridine calcium channel blocker (amlodipine) or a thiazide-like diuretic (chlorthalidone or indapamide). 1, 3

• ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazides/thiazide-like diuretics have demonstrated the most effective reduction in BP and cardiovascular events 1
• Fixed-dose single-pill combinations improve adherence and are strongly recommended over separate pills 1
• Beta-blockers should be reserved for compelling indications (angina, post-MI, heart failure, rate control) and combined with other first-line agents 1

Escalation Strategy

• If BP remains uncontrolled on dual therapy, escalate to triple-drug combination: RAS blocker + dihydropyridine CCB + thiazide-like diuretic, preferably as single-pill combination 1
• Never combine two RAS blockers (ACE inhibitor + ARB) 1
• Substitute chlorthalidone or indapamide for hydrochlorothiazide when using thiazide diuretics for superior efficacy 1

Essential Lifestyle Modifications (Implement Simultaneously with Medications)

Weight Loss (Most Effective Single Intervention)

• Target ideal body weight; expect approximately 1 mmHg SBP reduction per 1 kg weight loss 1
• Average BP reduction: 5 mmHg in hypertensive patients, 3 mmHg in normotensive 1

DASH Diet

• Emphasize fruits, vegetables, whole grains, low-fat dairy products with reduced saturated and total fat 1
• Produces 11 mmHg SBP reduction in hypertensive patients, 3 mmHg in normotensive 1
• Particularly effective in Black patients 1

Sodium Restriction

• Target <1,500 mg sodium/day; any reduction is beneficial 1
• Expect 1-3 mmHg SBP reduction per 1,000 mg sodium reduction 1
• Average reduction: 5 mmHg in hypertensive patients 1
• Augments BP-lowering effects of RAS blocker therapy 1

Potassium Supplementation

• Target 3,500-5,000 mg/day through dietary modification 1
• Contraindicated in CKD or with potassium-sparing medications 1
• Average reduction: 5 mmHg in hypertensive patients 1

Aerobic Exercise

• Brisk walking 5-7 times/week, 30-60 minutes/session, minimum 150 minutes/week 1
• Average reduction: 5 mmHg in hypertensive patients 1

Alcohol Moderation

• Men: ≤2 standard drinks/day (maximum 14/week) 1
• Women: ≤1 standard drink/day (maximum 9/week) 1
• Average reduction: 4 mmHg in hypertensive patients 1

Blood Pressure Targets

Target systolic BP of 120-129 mmHg in most adults to reduce cardiovascular risk, provided treatment is well tolerated. 1

• For adults <65 years: <130/80 mmHg 2, 3
• For adults ≥65 years: systolic <130 mmHg if ambulatory and community-dwelling 2
• If target of 120-129 mmHg is poorly tolerated, use "as low as reasonably achievable" (ALARA) principle 1
• Each 10 mmHg SBP reduction decreases CVD events by 20-30% 3

Critical Implementation Strategies

Medication Adherence Enhancement

• Prescribe once-daily dosing at the most convenient time for the patient 1
• Use fixed-dose single-pill combinations whenever possible 1
• Switch from 30-day to 90-day refills 1
• Implement team-based care with pharmacists, nurses, and community health workers 1

Follow-Up Schedule

• Stage 2 hypertension or high-risk stage 1: reassess in 1 month 2
• Stage 1 hypertension (low risk) or elevated BP: reassess in 3-6 months 2
• Very high BP (≥180/110 mmHg): prompt evaluation within 1 week 2
• Monthly visits until BP target achieved 1

Common Pitfalls to Avoid

Diagnostic Errors

• Confirm diagnosis with accurate office measurements and home BP monitoring or 24-hour ambulatory monitoring before initiating treatment 2
• Screen for secondary hypertension in adults diagnosed before age 40 (except obese young adults—start with sleep apnea evaluation) 1

Treatment Errors

• Do not use monotherapy for stage 2 hypertension or BP >20/10 mmHg above target 1
• Avoid combining two RAS blockers 1
• Do not use renal denervation as first-line therapy—lacks adequate outcomes data 1
• Maintain BP-lowering treatment lifelong, even beyond age 85 if well tolerated 1

Special Populations

• Exercise caution when initiating dual therapy in patients ≥85 years, those with symptomatic orthostatic hypotension, or moderate-to-severe frailty 1
• Monitor carefully for hypotension in older adults starting combination therapy 1

Resistant Hypertension Considerations

If BP remains uncontrolled on triple therapy, assess for:

• Medication non-adherence 2
• Secondary causes of hypertension 2
• Excessive sodium intake (particularly important in resistant hypertension) 1
• Consider lifestyle modifications which have demonstrated efficacy even in resistant hypertension 4