What is the recommended management approach for a patient with hypertension, including lifestyle modifications and pharmacological therapy?

Hypertensive Drug Management

For patients with confirmed hypertension, initiate lifestyle modifications immediately for blood pressure >120/80 mmHg, and add pharmacological therapy promptly for blood pressure ≥140/90 mmHg using thiazide-like diuretics, ACE inhibitors, ARBs, or calcium channel blockers as first-line agents, with target blood pressure <130/80 mmHg for most adults under 65 years. 1

Blood Pressure Targets

• Target <130/80 mmHg for adults under 65 years and high-risk patients (diabetes, chronic kidney disease, established cardiovascular disease) 1, 2
• Target systolic <130 mmHg for adults ≥65 years 1, 2
• For patients with low absolute cardiovascular risk or history of adverse effects from intensive control, a higher target of <140/90 mmHg is acceptable if safely attained 3

Lifestyle Modifications (Initiate for BP >120/80 mmHg)

Dietary interventions provide substantial additive blood pressure reductions:

• Sodium restriction to <2,300 mg/day (ideally <1,500 mg/day) produces 5-10 mmHg systolic reduction 3, 1
• DASH dietary pattern with 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy reduces systolic/diastolic BP by 11.4/5.5 mmHg 3, 1
• Increase potassium intake through foods like avocados, nuts, seeds, legumes, and leafy vegetables 3, 1

Weight and activity modifications:

• Weight loss of 10 kg reduces systolic BP by 6.0 mmHg and diastolic by 4.6 mmHg in overweight/obese patients 1, 2
• Regular aerobic exercise (minimum 30 minutes most days) produces 4 mmHg systolic and 3 mmHg diastolic reduction 3, 1

Alcohol and smoking:

• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women (10g alcohol/standard drink) 3, 1
• Smoking cessation is mandatory given its major cardiovascular risk 3

Pharmacological Treatment Algorithm

Initial Monotherapy (BP 140-159/90-99 mmHg)

First-line drug classes with proven cardiovascular benefit:

• Thiazide-like diuretics (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 3, 1
• ACE inhibitors (e.g., lisinopril 10-40 mg daily) 3, 1
• ARBs (e.g., losartan 50-100 mg daily) 3, 1
• Calcium channel blockers (amlodipine 5-10 mg daily) 3, 1

Race-specific considerations:

• For Black patients, initiate with calcium channel blocker or thiazide diuretic rather than ACE inhibitor/ARB as monotherapy, as these agents are more effective in this population 1, 2

Dual Therapy (BP ≥160/100 mmHg or Uncontrolled on Monotherapy)

For BP ≥160/100 mmHg, initiate two drugs simultaneously from different classes to achieve rapid control 3, 1

Preferred two-drug combinations:

• ACE inhibitor/ARB + calcium channel blocker 1
• ACE inhibitor/ARB + thiazide diuretic 1
• For Black patients specifically, calcium channel blocker + thiazide diuretic may be more effective than calcium channel blocker + ACE inhibitor/ARB 1, 2

Triple Therapy (Uncontrolled on Dual Therapy)

Standard triple therapy combination:

• ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic targets three complementary mechanisms: renin-angiotensin system blockade, vasodilation, and volume reduction 1
• Multiple-drug therapy is generally required to achieve blood pressure targets 3

Resistant Hypertension (Fourth-Line Agent)

Resistant hypertension is defined as BP ≥140/90 mmHg despite:

• Appropriate lifestyle management 3
• A diuretic plus two other antihypertensive drugs from different classes at adequate doses 3

Before diagnosing resistant hypertension, exclude:

• Medication nonadherence (most common cause) 1
• Interfering medications (NSAIDs, decongestants, oral contraceptives, systemic corticosteroids) 1
• Secondary causes (primary aldosteronism, renal artery stenosis, obstructive sleep apnea) 1

If truly resistant, add spironolactone 25-50 mg daily as the preferred fourth-line agent 1

Special Population: Diabetes with Albuminuria

For diabetic patients with urinary albumin-to-creatinine ratio ≥30 mg/g:

• ACE inhibitor or ARB at maximum tolerated dose is recommended first-line treatment 3, 1
• If one class is not tolerated, substitute the other 3
• Initiate pharmacologic therapy promptly for confirmed BP ≥140/90 mmHg in addition to lifestyle modifications 1

Critical Pitfalls to Avoid

Never combine these drug classes:

• Do NOT combine ACE inhibitor with ARB (dual RAS blockade increases hyperkalemia and acute kidney injury without additional cardiovascular benefit) 3, 1
• Do NOT combine ACE inhibitor or ARB with direct renin inhibitors 3

Beta-blocker considerations:

• Do NOT add beta-blocker as second or third agent unless compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, heart rate control needed), as beta-blockers are less effective than diuretics for stroke prevention 1

Pregnancy contraindications:

• ACE inhibitors, ARBs, and spironolactone are contraindicated in pregnancy due to fetal damage risk 3
• Target BP 110-135/85 mmHg during pregnancy to reduce accelerated maternal hypertension while minimizing fetal growth impairment 3

Monitoring and Follow-Up

Initial monitoring:

• Reassess BP within 2-4 weeks after initiating or adjusting therapy 1, 2
• Achieve target BP within 3 months of treatment initiation or modification 1, 2

Laboratory monitoring:

• For patients on ACE inhibitor, ARB, or diuretic, monitor serum creatinine/eGFR and potassium at least annually 3
• Check potassium and creatinine 2-4 weeks after initiating ACE inhibitor, ARB, or diuretic to detect hyperkalemia, hypokalemia, or renal function changes 1

Confirmation of diagnosis:

• Use home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) in addition to office measurements, as white coat hypertension affects 15-30% of patients 1