What is the best approach to manage a patient with hypertension?

Managing Hypertension: A Comprehensive Evidence-Based Approach

For most adults with hypertension, initiate both lifestyle modifications AND combination pharmacotherapy simultaneously targeting blood pressure <130/80 mmHg, using an ACE inhibitor or ARB plus either a calcium channel blocker or thiazide diuretic as first-line treatment. 1, 2, 3

Diagnosis and Confirmation

• Confirm hypertension with multiple office measurements showing BP ≥140/90 mmHg, or use out-of-office monitoring: home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) to exclude white coat hypertension 2, 3
• For office BP 140-159/90-99 mmHg, confirm via home or ambulatory monitoring within 1 month before starting treatment 2
• Office BP ≥160/100 mmHg requires rapid confirmation (within 1 month), while BP ≥180/110 mmHg demands immediate evaluation to exclude hypertensive emergency 2
• Measure standing BP in elderly patients and those with diabetes to assess for orthostatic hypotension 3

Essential Initial Workup

• Obtain urinalysis for blood and protein, serum creatinine with eGFR calculation, urine albumin-to-creatinine ratio, blood glucose, complete lipid profile, serum electrolytes, and 12-lead ECG for all newly diagnosed patients 1, 2, 3
• Perform formal cardiovascular risk assessment using SCORE2 (ages 40-69) or SCORE2-OP (ages ≥70) to guide treatment intensity 2
• Screen for secondary hypertension if: age <30 years requiring treatment, resistant hypertension (≥3 drugs), sudden onset/worsening, or suggestive clinical features such as hypokalemia or abdominal bruit 2, 3
• Consider aldosterone-to-renin ratio in all patients with difficult-to-control or resistant hypertension 3

Blood Pressure Targets

Target BP 120-129/<80 mmHg for most adults when treatment is well tolerated 1, 2

• For patients with diabetes, chronic kidney disease, or established cardiovascular disease: target <130/80 mmHg 1, 2, 3
• For adults ≥65 years: target systolic <130 mmHg 2
• These lower targets provide 35-40% reduction in stroke, 20-25% reduction in myocardial infarction, and 50% reduction in heart failure 1, 3

Lifestyle Modifications (Implement Immediately Alongside Pharmacotherapy)

Critical principle: Do not delay pharmacotherapy for a trial of lifestyle changes alone—implement both simultaneously 2, 3

Dietary Interventions

• DASH diet emphasizing 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy, whole grains, and reduced saturated fat lowers SBP by 5-8 mmHg 1, 2, 3, 4
• Sodium restriction to <2 g/day (approximately 5 g salt/day) reduces SBP by 5-8 mmHg—eliminate table salt and avoid processed foods 1, 2, 3, 4
• Potassium supplementation through dietary sources (fruits/vegetables) unless contraindicated by CKD 2
• Limit free sugar to <10% of energy intake, particularly avoiding sugar-sweetened beverages 2

Weight Management

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women), providing approximately 1 mmHg SBP reduction per 1 kg weight loss 1, 2, 3, 5

Physical Activity

• Minimum 150 minutes/week of moderate-intensity aerobic exercise (30 minutes, 5-7 days/week) plus resistance training 2-3 times/week reduces SBP by 4-9 mmHg 1, 2, 3, 5

Alcohol Moderation

• Limit to <100 g/week of pure alcohol (≤2 drinks/day for men, ≤1 drink/day for women) lowers SBP by 2-4 mmHg, with complete abstinence preferred for optimal health outcomes 1, 2, 3, 4

Tobacco Cessation

• Complete smoking cessation with referral to cessation programs is mandatory as smoking independently causes cardiovascular disease 2

Pharmacological Treatment Algorithm

When to Initiate Treatment

Immediate pharmacotherapy is indicated for: 1, 2, 3

• BP ≥140/90 mmHg regardless of cardiovascular risk
• BP 130-139/80-89 mmHg with high cardiovascular risk (≥10% 10-year risk, diabetes, CKD, or established CVD)

First-Line Combination Therapy

Most patients should start with two-drug combination therapy, preferably as a single-pill combination to improve adherence 2, 3, 5

Preferred initial combinations: 1, 2, 3, 6, 7

• ACE inhibitor (e.g., lisinopril) or ARB + dihydropyridine calcium channel blocker (e.g., amlodipine)
• ACE inhibitor or ARB + thiazide/thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide)

Titration Strategy

• Achieve BP control within 3 months with monthly follow-up visits until target is reached 2, 3
• Recheck BP in 1 month after any medication change 2
• If BP not controlled with two drugs at maximum tolerated doses, add a third agent from a different class 2, 3

Special Population Considerations

Diabetes

• ACE inhibitor or ARB is mandatory as first-line therapy to reduce progression of diabetic nephropathy 2
• Target BP <130/80 mmHg 1, 2, 3

Chronic Kidney Disease

• ACE inhibitor or ARB for patients with albuminuria (UACR ≥30 mg/g) to reduce progressive kidney disease 2
• Target BP <130/80 mmHg 1, 2, 3
• For dialysis patients, target predialysis BP 140/90 mmHg provided no substantial orthostatic or intradialytic hypotension occurs 8

Coronary Artery Disease

• ACE inhibitor or ARB as first-line therapy 2
• Beta-blockers indicated if history of myocardial infarction or heart failure 8, 2

Heart Failure

• Combination of ACE inhibitor/ARB, beta-blocker, diuretic, and mineralocorticoid receptor antagonist per heart failure guidelines 8, 2

Metabolic Syndrome

• Angiotensin receptor antagonists or ACE inhibitors preferred due to lower incidence of new-onset diabetes 8
• Avoid traditional beta-blockers due to adverse metabolic effects; consider vasodilating beta-blockers (carvedilol, nebivolol) if needed 8
• Calcium antagonists are metabolically neutral and appropriate 8

Pregnancy or Planning Pregnancy

• Absolute contraindications: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors (cause fetal injury/death) 2
• Preferred agents: methyldopa, nifedipine, or labetalol 2

Resistant Hypertension Management

Definition: BP ≥140/90 mmHg (or ≥130/80 mmHg per newer guidelines) on ≥3 antihypertensive medications at maximum tolerated doses including a diuretic, or BP controlled but requiring ≥4 drugs 8, 3

Systematic Approach: 3

1. Exclude pseudo-resistance (white coat hypertension, improper BP measurement technique)
2. Assess medication adherence
3. Screen for secondary causes (primary aldosteronism, renal artery stenosis, obstructive sleep apnea)
4. Identify interfering substances (NSAIDs, decongestants, excessive alcohol, illicit drugs)
5. Optimize diuretic therapy (ensure adequate dose, consider switching to chlorthalidone)
6. Add aldosterone antagonist (spironolactone or eplerenone)
7. If still uncontrolled after achieving dry weight and three drugs, consider minoxidil 8
8. For dialysis patients with refractory hypertension despite minoxidil, consider continuous ambulatory peritoneal dialysis or bilateral nephrectomy 8

Implementation Strategies

• Team-based care with multidisciplinary teams, telehealth strategies, and enhanced electronic health record connectivity is the most effective approach for achieving BP control 1, 3
• Home BP monitoring with validated devices facilitates medication titration and maintenance of BP goals 1, 2, 3
• Simplify regimens to once-daily dosing when possible and use single-pill combinations to improve adherence 1, 2
• Address financial barriers and minimize cost of therapy 1

Clinical Benefits of Effective BP Control

• For every 10 mmHg SBP reduction: 20-30% reduction in CVD events 3, 5
• For every 12 mmHg SBP reduction maintained over 10 years: one death prevented for every 11 treated patients with additional cardiovascular risk factors 1
• Intensive BP lowering may prevent or partially arrest cognitive decline in older adults 3

Common Pitfalls to Avoid

• Delaying pharmacotherapy for lifestyle modification trial alone—this is outdated practice; implement both simultaneously 2, 3
• Failing to confirm elevated readings with multiple measurements or out-of-office monitoring before diagnosis 1, 2, 3
• Not considering white coat hypertension when office readings are elevated 2, 3
• Inadequate dosing or using monotherapy when combination therapy is indicated 2, 3
• Starting with beta-blockers in metabolic syndrome (adverse metabolic effects) 8
• Overlooking the need for lower BP targets (<130/80 mmHg) in high-risk patients with diabetes, CKD, or established CVD 1, 2, 3
• Using ACE inhibitors or ARBs in women of childbearing potential without contraception counseling 2
• Not screening for secondary hypertension in resistant cases 2, 3