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

Managing Hypertension: A Comprehensive Evidence-Based Approach

For most adults with hypertension, initiate combination pharmacotherapy immediately alongside lifestyle modifications targeting a blood pressure of 120-129/<80 mmHg, using an ACE inhibitor or ARB plus either a dihydropyridine 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 (daytime mean ≥130/80 mmHg) to exclude white coat hypertension 1, 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, preferably within 1 month 2
• Office 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 calculate 10-year CVD risk 2
• Patients with ≥10% 10-year CVD risk, established CVD, moderate-to-severe CKD (eGFR <60), diabetes, or hypertension-mediated organ damage are automatically high-risk and require aggressive treatment 2
• Screen for secondary hypertension if: age <30 years requiring treatment, resistant hypertension (≥3 drugs), sudden onset/worsening hypertension, or suggestive clinical features (hypokalemia, abdominal bruit, young age) 2, 3
• Consider aldosterone-to-renin ratio screening in all patients with difficult-to-control or resistant hypertension 3

Blood Pressure Targets

Target 120-129 mmHg systolic and <80 mmHg diastolic for most adults when treatment is well tolerated 1, 2

• For patients with diabetes, CKD, or established CVD: target <130/80 mmHg 1, 2, 3
• For adults ≥65 years: target systolic <130 mmHg 2
• For hemodialysis patients: target predialysis BP 140/90 mmHg (measured sitting) if no substantial orthostatic or intradialytic hypotension occurs 4

Lifestyle Modifications (Implement Immediately, Not as Delay to Treatment)

Do not delay pharmacotherapy for a trial of lifestyle changes alone—initiate both simultaneously 2, 3

Dietary Interventions

• DASH diet (8-10 servings/day fruits and vegetables, 2-3 servings/day low-fat dairy, whole grains, reduced saturated fat) lowers SBP by 5-8 mmHg 1, 2, 3, 5
• Sodium restriction to <2 g/day (approximately 5 g salt/day) reduces SBP by 5-8 mmHg 1, 2, 6
• Eliminate table salt and processed foods high in sodium 3, 6
• Increase dietary potassium through fruits and 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) 1, 2, 3
• Each 1 kg weight loss provides approximately 1 mmHg SBP reduction 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 ≤2 drinks/day for men and ≤1 drink/day for women (maximum 100 g/week pure alcohol), with complete abstinence preferred for optimal health outcomes 1, 2, 3, 5
• Alcohol moderation lowers SBP by 2-4 mmHg 1

Tobacco Cessation

• Complete tobacco cessation with referral to cessation programs is mandatory as smoking independently causes CVD 2

Pharmacological Treatment Algorithm

When to Initiate Treatment

Immediate treatment with both lifestyle modifications AND medication: 2, 3

• BP ≥140/90 mmHg regardless of cardiovascular risk 1, 2, 3
• BP 130-139/80-89 mmHg with high CVD risk (≥10% 10-year risk, diabetes, CKD, or established CVD) 2

Initial Drug Selection

Most patients should start with two-drug combination therapy, preferably as a single-pill combination to improve adherence 1, 2, 3

Preferred initial combinations for non-Black patients: 1, 2, 3

• ACE inhibitor (e.g., lisinopril) or ARB + dihydropyridine calcium channel blocker (e.g., amlodipine) 1, 2, 7, 8
• ACE inhibitor or ARB + thiazide/thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) 1, 2, 3, 5

Special Population Considerations

Diabetes: 2, 3

• ACE inhibitor or ARB is mandatory as first-line therapy to reduce progression of diabetic nephropathy
• Target BP <130/80 mmHg
• Goal BP should probably be below 130/80 mmHg based on HOT study data 4

Chronic Kidney Disease with albuminuria (UACR ≥30 mg/g): 2, 3

• ACE inhibitor or ARB mandatory to reduce progressive kidney disease
• Target BP <130/80 mmHg
• For proteinuria >1 g/24 hours, goal BP 125/75 mmHg provides maximum protection (except in African-Americans where no difference was observed) 4

Coronary Artery Disease or Prior Myocardial Infarction: 4, 2

• ACE inhibitor or ARB as first-line therapy
• Beta-blockers indicated if history of myocardial infarction or heart failure
• Beta-blocker exposure associated with decreased mortality in CKD 4

Heart Failure: 4, 2

• Combination of ACE inhibitor/ARB, beta-blocker, diuretic, and mineralocorticoid receptor antagonist per heart failure guidelines
• Diuretics, ACE inhibitors (or ARBs), beta-blockers, and aldosterone receptor antagonists recommended 1

Metabolic Syndrome: 4

• Angiotensin receptor antagonists or ACE inhibitors associated with lower incidence of diabetes
• Add dihydropyridine or non-dihydropyridine calcium antagonist if BP not controlled
• Low-dose thiazide diuretic may be considered as second or third step
• Avoid beta-blockers unless specific indication due to adverse effects on insulin sensitivity and new-onset diabetes (exception: vasodilating beta-blockers like carvedilol and nebivolol)

Pregnancy or Planning Pregnancy: 2

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

Hemodialysis Patients: 4

• Achieve dry weight and reduce extracellular fluid volume as first priority
• ACE inhibitors or ARBs as first-line pharmacotherapy (ARBs may be more potent and reduce LVH)
• Beta-blockers for patients with previous MI or established CAD
• Calcium channel antagonists and anti-alpha-adrenergic drugs as additional agents
• ACE inhibitor use associated with decreased mortality in observational studies

Titration and Escalation 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 1, 2
• Monitor serum creatinine and potassium 2-4 weeks after initiating or increasing dose of ACE inhibitor/ARB 2

Resistant Hypertension Management

Definition: BP ≥130/80 mmHg (or ≥140/90 mmHg per older guidelines) on ≥3 antihypertensive medications at maximum tolerated doses including a diuretic, or BP controlled but requiring ≥4 drugs 4, 2, 3

Systematic approach: 2, 3

1. Exclude pseudo-resistance:

   • Confirm with home or ambulatory BP monitoring to rule out white coat effect
   • Ensure proper BP measurement technique (correct cuff size, arm position)
   • Assess medication adherence

2. Screen for secondary causes:

   • Primary aldosteronism (aldosterone-to-renin ratio)
   • Renal artery stenosis (especially if abdominal bruit, flash pulmonary edema)
   • Obstructive sleep apnea
   • Pheochromocytoma
   • Cushing's syndrome
   • Thyroid disorders

3. Identify interfering substances:

   • NSAIDs, decongestants, stimulants, oral contraceptives, corticosteroids, licorice, excessive alcohol

4. Optimize diuretic therapy:

   • Ensure adequate diuretic dose (chlorthalidone 12.5-25 mg preferred over hydrochlorothiazide)
   • Consider loop diuretic if eGFR <30 mL/min/1.73m²

5. Add mineralocorticoid receptor antagonist (spironolactone or eplerenone) 2, 3

6. For severe resistant hypertension in dialysis patients: 4

   • If BP not controlled with dialysis and three antihypertensive agents of different classes, evaluate for secondary causes
   • If no evident cause found and patient remains hypertensive after trial with minoxidil, consider continuous ambulatory peritoneal dialysis (CAPD)
   • If CAPD ineffective, consider surgical or embolic nephrectomy

Implementation Strategies for BP Control

• Use team-based care with multidisciplinary teams, telehealth strategies, and enhanced connectivity between patient, provider, and electronic health records 1, 3
• Simplify regimen to once-daily dosing when possible 1
• Incorporate treatment into patient's daily lifestyle 1
• Minimize cost of therapy and recognize financial barriers 1
• Encourage self-monitoring with validated home BP devices and use telemonitoring for medication titration 1, 3

Clinical Benefits of Effective BP Control

• For every 10 mmHg SBP reduction: 20-30% reduction in CVD events 3, 5
• 35-40% reduction in stroke incidence 1, 3
• 20-25% reduction in myocardial infarction 1, 3
• 50% reduction in heart failure 1
• For every 12 mmHg reduction in SBP maintained over 10 years, one death is prevented for every 11 treated patients with additional cardiovascular risk factors 1

Common Pitfalls to Avoid

• Delaying pharmacotherapy for a trial of lifestyle changes alone in patients with BP ≥140/90 mmHg or ≥130/80 mmHg with high CVD risk 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 inappropriate drug combinations 1
• Starting with monotherapy instead of combination therapy in most patients 2, 3
• Not addressing lifestyle modifications alongside pharmacological treatment 1, 2, 6
• Overlooking the need for lower BP targets (<130/80 mmHg) in high-risk patients with diabetes, CKD, or established CVD 1, 2, 3
• Using beta-blockers as first-line therapy in metabolic syndrome without specific indication 4
• Failing to screen for secondary hypertension in resistant cases 2, 3
• Not optimizing diuretic therapy before adding additional agents in resistant hypertension 2, 3