What is the best approach to manage stage 1 hypertension in an adult patient with a BP of 152/91 mmHg?

Management of Stage 1 Hypertension (BP 152/91 mmHg)

For this patient with stage 1 hypertension (BP 152/91 mmHg), you must calculate the 10-year ASCVD risk immediately—if ≥10% or if diabetes, CKD, or established CVD is present, start both lifestyle modifications AND pharmacologic therapy today; if ASCVD risk is <10%, initiate intensive lifestyle modifications alone and reassess in 3-6 months. 1

Immediate Risk Stratification

Calculate 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations before deciding on treatment intensity. 1, 2 This single calculation determines whether you start medication immediately or defer to lifestyle-only intervention.

Treatment Decision Algorithm:

High-Risk Patients (Start Medication + Lifestyle TODAY):

• 10-year ASCVD risk ≥10% 1, 2
• Diabetes mellitus present 1
• Chronic kidney disease present 1
• Established cardiovascular disease 1

Lower-Risk Patients (Lifestyle Only, Reassess in 3-6 Months):

• 10-year ASCVD risk <10% AND no diabetes, CKD, or CVD 1, 2

Required Initial Laboratory Workup

Before initiating any treatment, obtain these specific tests to identify comorbidities and secondary causes: 1

• Fasting blood glucose and hemoglobin A1C 1
• Lipid panel 1
• Serum creatinine with eGFR 1
• Serum electrolytes 1
• Urinalysis 1
• 12-lead ECG 1
• TSH 1

Lifestyle Modifications (ALL Patients)

Implement all of the following interventions simultaneously, as their effects are additive: 3

Weight Loss

• Target BMI 20-25 kg/m² (current BMI = 28.9 kg/m²) 2
• Expected BP reduction: 5 mm Hg systolic per 5 kg weight loss 3
• This patient needs to lose approximately 10-15 kg to reach target BMI 2

Dietary Sodium Restriction

• Optimal goal: <1,500 mg/day sodium 3, 1
• Minimum reduction: 1,000 mg/day from current intake 3
• Expected BP reduction: 5-6 mm Hg systolic 3
• Most dietary sodium comes from processed foods and restaurant meals, not the salt shaker 3

Dietary Potassium Supplementation

• Target: 3,500-5,000 mg/day through diet 3, 1
• Expected BP reduction: 4-5 mm Hg systolic 3
• Achieve through fruits, vegetables, and low-fat dairy 3

DASH Diet Pattern

• Rich in fruits, vegetables, whole grains, low-fat dairy 3, 1
• Reduced saturated and total fat 3
• Expected BP reduction: 11 mm Hg systolic 3
• The DASH diet is especially effective in Black patients 3
• When combined with sodium reduction, effects are substantially increased 3

Physical Activity

• Aerobic exercise: 90-150 minutes/week at 65-75% heart rate reserve 3
• Expected BP reduction: 5-8 mm Hg systolic 3
• Alternative: Dynamic resistance training 90-150 minutes/week 3

Alcohol Moderation

• Men: ≤2 standard drinks daily 3
• Women: ≤1 standard drink daily 3
• One standard drink = 12 oz beer (5% alcohol), 5 oz wine (12% alcohol), or 1.5 oz spirits (40% alcohol) 3
• Expected BP reduction: 4 mm Hg systolic 3

Pharmacologic Therapy (If High-Risk)

First-Line Medication Options

For patients requiring medication, choose ONE of these first-line agents: 3, 1

1. Thiazide or thiazide-like diuretics (preferred initial choice) 3, 1

   • Chlorthalidone superior to other agents in preventing heart failure 3
   • More effective than ACE inhibitors in Black patients 3

2. Calcium channel blockers (CCBs) 3, 1

   • Good alternative when thiazides not tolerated 3
   • As effective as diuretics except for heart failure prevention 3

3. ACE inhibitors or ARBs 3, 1

   • Less effective than thiazides and CCBs in Black patients for stroke prevention 3
   • ARBs better tolerated than ACE inhibitors (less cough, less angioedema) 3

Critical caveat: ACE inhibitors were notably less effective than CCBs in preventing heart failure and stroke in Black patients, making thiazide diuretics (especially chlorthalidone) or CCBs the best initial choice for single-drug therapy in this population. 3

When to Start Two Medications Simultaneously

Start with 2-drug combination therapy if BP is >20/10 mm Hg above target (i.e., BP >150/90 mmHg for target <130/80). 3 This patient at 152/91 mmHg is borderline for this threshold—use clinical judgment based on tolerability concerns and age. 3

Preferred 2-drug combinations: 3

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB 3
• RAS blocker + thiazide/thiazide-like diuretic 3

Use single-pill combination products when prescribing 2-drug therapy to improve adherence. 3

Blood Pressure Target

Target BP: <130/80 mmHg 1, 2, 4

The 2024 ESC guidelines recommend an even lower target of 120-129 mmHg systolic if well tolerated, based on SPRINT trial data showing 25% reduction in primary CVD outcomes and 27% lower total mortality with intensive BP control (SBP <120 mmHg). 3 However, the ACC/AHA guideline uses <130/80 mmHg as the standard target to account for real-world BP measurement variability. 1, 2

For patients ≥65 years: Target SBP <130 mmHg, but monitor carefully for orthostatic hypotension and adverse effects. 3, 4

Follow-Up Schedule

Lifestyle modifications only (ASCVD risk <10%): Reassess BP in 3-6 months 1, 2

Pharmacologic therapy initiated (ASCVD risk ≥10%): Reassess BP in 1 month 1, 2

Common Pitfalls to Avoid

• Do not rely on single office BP measurement—confirm with home BP monitoring or ambulatory BP monitoring before diagnosing hypertension 2
• Do not use beta-blockers as first-line therapy—they are less effective than diuretics and CCBs for stroke prevention 3
• Do not combine two RAS blockers (ACE inhibitor + ARB)—this is not recommended 3
• Do not undertreated diastolic hypertension—confirmed DBP ≥90 mmHg has "A" level evidence for treatment benefit 3
• Do not assume older adults cannot tolerate intensive BP control—SPRINT showed benefits in adults ≥75 years without increased overall serious adverse events 3