What are the guidelines for managing hypertension in patients, including lifestyle modifications and medication options?

Hypertension Management Guidelines

Blood Pressure Targets

For most adults, target blood pressure should be <140/90 mmHg minimum, with an optimal goal of <130/80 mmHg if tolerated. 1

• For patients with diabetes, chronic kidney disease, or established cardiovascular disease, the target is <130/80 mmHg 2
• For adults aged ≥65 years, systolic blood pressure <130 mmHg is recommended 3
• For younger adults (<65 years), systolic blood pressure of 120-129 mmHg is optimal if well tolerated 1

Lifestyle Modifications

All patients with hypertension or prehypertension (120-139/80-89 mmHg) should implement lifestyle changes immediately, as these provide additive blood pressure reductions of 10-20 mmHg. 2

Specific lifestyle interventions include:

• Sodium restriction to <2,300 mg/day (ideally <2,000 mg/day), which reduces systolic blood pressure by 5-10 mmHg 2, 1
• Weight reduction targeting BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women), with 10 kg weight loss producing 6.0/4.6 mmHg reduction 1
• DASH or Mediterranean diet pattern with increased fruit, vegetable, and potassium intake while decreasing saturated fat 2, 1
• Regular aerobic exercise of 150 minutes/week moderate-intensity plus resistance training 2-3 times/week, producing 4/3 mmHg reduction 2, 1
• Alcohol limitation to ≤2 drinks/day for men or ≤1 drink/day for women (maximum 14/week for men, 9/week for women) 2
• Smoking cessation for all patients 2

Pharmacological Treatment Initiation

When to start medication:

Initiate antihypertensive drug therapy immediately if systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥100 mmHg. 2

• For blood pressure 140-159/90-99 mmHg, initiate treatment if cardiovascular disease, target organ damage, or 10-year cardiovascular risk ≥20% is present 2
• For blood pressure 130-139/80-89 mmHg, provide lifestyle therapy for maximum 3 months, then add pharmacotherapy if targets not achieved 2
• For patients with diabetes, initiate drug therapy if blood pressure ≥140/90 mmHg 2

First-line medication choices:

Thiazide-type diuretics should be used as initial therapy for most patients with uncomplicated hypertension, either alone or combined with an ACE inhibitor, ARB, or calcium channel blocker. 2

• For non-Black patients: Start with thiazide diuretic + ACE inhibitor or ARB, or thiazide diuretic + calcium channel blocker 1
• For Black patients: Start with thiazide diuretic + calcium channel blocker, as ACE inhibitors/ARBs are less effective as monotherapy in this population 1
• Chlorthalidone is preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes data 1

Treatment Escalation Strategy

Most patients with hypertension will require two or more medications to achieve blood pressure goals. 2

For Stage 2 hypertension (≥160/100 mmHg):

Initiate therapy with two drugs from different classes immediately, preferably as a single-pill combination. 1

• If blood pressure is >20/10 mmHg above goal, start with two agents simultaneously 2
• Single-pill combinations significantly improve medication adherence and should be strongly preferred 1

Sequential treatment algorithm:

1. Start with dual therapy: Thiazide diuretic + (ACE inhibitor or ARB or calcium channel blocker) 2, 1
2. If uncontrolled after 1 month at adequate doses, add third agent to create triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 1
3. If uncontrolled on triple therapy, add spironolactone 25-50 mg daily as the preferred fourth-line agent for resistant hypertension 1

Special Populations

Patients with diabetes:

Target blood pressure <130/80 mmHg using ACE inhibitors or ARBs as preferred agents, particularly if albuminuria is present. 2

• ACE inhibitors or ARBs provide additional renal protection in diabetic patients with albuminuria 2
• For patients ≥55 years with diabetes and another cardiovascular risk factor, ACE inhibitors reduce cardiovascular events even without hypertension 2

Patients with chronic kidney disease:

Target blood pressure <130/80 mmHg with ACE inhibitors or ARBs as preferred agents. 2

Patients with left ventricular hypertrophy:

Start with losartan 50 mg daily, add hydrochlorothiazide 12.5 mg daily, then increase losartan to 100 mg daily followed by hydrochlorothiazide to 25 mg daily based on response. 4

Monitoring and Follow-up

Reassess blood pressure within 1 month after initiating or modifying therapy, with the goal of achieving target blood pressure within 3 months. 1

• For blood pressure ≥160/100 mmHg, initiate treatment immediately without waiting for confirmation 2
• For blood pressure <160/100 mmHg, reexamine within 1 month to confirm hypertension diagnosis 2
• Consider home blood pressure monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) to confirm office readings 1

Critical Pitfalls to Avoid

Never combine an ACE inhibitor with an ARB, as this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit. 2, 1

• Avoid beta-blockers as initial therapy unless compelling indications exist (heart failure, post-MI, angina, or rate control needed) 1
• Do not use thiazide diuretics combined with beta-blockers in patients at high risk for diabetes (strong family history, obesity, impaired glucose tolerance, metabolic syndrome, South Asian or African-Caribbean descent) 2
• Monitor renal function and serum potassium when using ACE inhibitors or ARBs, especially in patients with chronic kidney disease 2
• Verify medication adherence before escalating therapy, as non-adherence is the most common cause of apparent treatment resistance 1

Aspirin and Statin Therapy

For patients aged ≥50 years with controlled blood pressure (<150/90 mmHg) and target organ damage, diabetes, or 10-year cardiovascular risk ≥20%, add aspirin 75 mg daily. 2

For patients with 10-year cardiovascular risk ≥20% and total cholesterol ≥3.5 mmol/L, initiate statin therapy targeting 25% reduction in total cholesterol or 30% reduction in LDL cholesterol. 2