What is the recommended treatment approach for a patient with hypertension, considering lifestyle modifications and pharmacological interventions, especially for those with a history of cardiovascular disease or diabetes?

Hypertension Management: Treatment Approach for Patients with Cardiovascular Disease or Diabetes

For patients with hypertension and a history of cardiovascular disease or diabetes, initiate pharmacological therapy immediately alongside lifestyle modifications, targeting blood pressure <130/80 mmHg, with an ACE inhibitor or ARB as first-line treatment, particularly if albuminuria is present. 1, 2, 3

Blood Pressure Targets

• Target <130/80 mmHg for patients with diabetes, chronic kidney disease, or established cardiovascular disease 2, 3
• For adults ≥65 years, target systolic blood pressure <130 mmHg 2
• Blood pressure should be measured at every routine diabetes visit, with confirmation on a separate day if readings are ≥130/80 mmHg 1

Lifestyle Modifications (Implement for ALL Patients)

Dietary Interventions:

• Adopt a DASH-style eating pattern with 8-10 servings of fruits and vegetables daily and 2-3 servings of low-fat dairy products 1, 3
• Restrict sodium intake to <2,300 mg/day (ideally 1,200-2,300 mg/day for patients with diabetes) 1, 3
• Increase dietary potassium intake to 3,500-5,000 mg/day through food sources 3
• Limit trans-unsaturated fatty acids to <1% of energy intake 3

Weight and Alcohol Management:

• Achieve weight loss through caloric restriction if overweight or obese; a 10 kg reduction can lower systolic BP by 6.0 mmHg and diastolic BP by 4.6 mmHg 2
• Limit alcohol to ≤2 standard drinks/day for men and ≤1 drink/day for women (maximum 14/week for men, 9/week for women) 1, 3

Physical Activity:

• Engage in at least 150 minutes of moderate-intensity aerobic exercise per week, distributed over at least 3 days with no more than 2 consecutive days without activity 1
• For long-term weight maintenance, 7 hours of moderate or vigorous aerobic activity per week may be needed 1

Pharmacological Treatment Algorithm

Step 1: Immediate Initiation Criteria

• For patients with diabetes, chronic kidney disease, or established cardiovascular disease: Start pharmacotherapy immediately regardless of BP level, in addition to lifestyle modifications 1, 3
• For BP ≥140/90 mmHg: Initiate drug therapy immediately alongside lifestyle changes 1
• For BP 130-139/80-89 mmHg without high-risk conditions: Trial lifestyle modifications for maximum 3 months; if target not achieved, add pharmacotherapy 1, 3

Step 2: First-Line Medication Selection

For Patients with Diabetes and Albuminuria (≥30 mg/g creatinine):

• ACE inhibitor or ARB at maximum tolerated dose is the mandatory first-line treatment 1, 3
• If one class is not tolerated, substitute with the other 1

For Patients with Cardiovascular Disease:

• ACE inhibitor or ARB is recommended as first-line therapy 2, 4
• Consider beta-blockers if coronary artery disease is present 4

For Patients without Albuminuria:

• Preferred initial approach: Two-drug combination therapy as single-pill combination (ACE inhibitor or ARB + dihydropyridine calcium channel blocker) 3
• Alternative first-line classes include thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers 1, 3

Step 3: Treatment Intensification

For BP ≥160/100 mmHg:

• Initiate two drugs or a single-pill combination immediately 1

If BP Remains Uncontrolled on Two Medications:

• Add a thiazide or thiazide-like diuretic to complete triple therapy (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 3
• Chlorthalidone is preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes 3
• Multiple-drug therapy is generally required to achieve BP targets 1

Step 4: Resistant Hypertension Management

Definition: BP ≥140/90 mmHg despite appropriate lifestyle management plus a diuretic and two other antihypertensive drugs at adequate doses 1

Before diagnosing resistant hypertension, exclude:

• Medication nonadherence (address cost and side effects barriers) 1
• White coat hypertension 1
• Secondary hypertension 1

Treatment:

• Add spironolactone (mineralocorticoid receptor antagonist) as the preferred fourth-line agent 1, 4
• Alternative options include amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 4

Critical Monitoring Requirements

Laboratory Monitoring:

• Monitor serum creatinine/eGFR and potassium within 7-14 days after starting or adjusting ACE inhibitors, ARBs, or diuretics 3
• If stable after first 3 months, follow-up every 6 months thereafter 1
• Recheck at least annually for patients on these medications 1

Blood Pressure Follow-Up:

• Reassess BP within 2-4 weeks after initiating or adjusting therapy 2, 3
• Target BP should be achieved within 3 months of treatment initiation 1, 3
• Once controlled, follow-up every 3-6 months 2, 3
• Encourage home BP monitoring throughout treatment 3

Orthostatic Measurements:

• Perform orthostatic BP measurements when clinically indicated, especially in elderly patients or those with diabetes 1, 3
• In elderly hypertensive patients, lower BP gradually to avoid complications 1

Important Caveats

Combination Restrictions:

• Never combine ACE inhibitors with ARBs 1
• Never combine ACE inhibitors or ARBs with direct renin inhibitors 1

Referral Criteria:

• Refer patients not achieving target BP despite multiple-drug therapy to a hypertension specialist 1

Special Population Considerations:

• For Black patients with diabetes, a calcium channel blocker + thiazide diuretic combination may be more effective than calcium channel blocker + ACE inhibitor/ARB 2
• For patients with heart failure, use ACE inhibitor or ARB + beta-blocker + diuretic (usually loop diuretic if volume overloaded) 3