What is the appropriate management for a patient with hypertension and associated vital signs?

Management of These Blood Pressure Readings

You need to initiate combination antihypertensive drug therapy immediately alongside lifestyle modifications, as these readings demonstrate Grade 2 hypertension (systolic ≥160 mmHg) that requires prompt pharmacological intervention. 1, 2

Blood Pressure Classification

Your readings show:

• 162/101 mmHg - Grade 2 hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg) 1
• 151/83 mmHg - Grade 1 hypertension (systolic 140-159 mmHg) 1
• 151/83 mmHg - Grade 1 hypertension 1

The highest reading (162/101 mmHg) determines your treatment category. 1

Immediate Actions Required

1. Confirm the Diagnosis

• Obtain out-of-office blood pressure measurements using either home blood pressure monitoring or 24-hour ambulatory monitoring before finalizing treatment, as office readings can overestimate true blood pressure by approximately 10/5 mmHg. 1, 2
• However, given your systolic BP ≥160 mmHg, do not delay treatment while awaiting confirmation—this level warrants immediate intervention. 1

2. Rule Out Hypertensive Emergency

You do not require urgent hospitalization unless you have: 1

• Severe hypertension >220/120 mmHg 1
• Grade III-IV retinopathy (accelerated/malignant hypertension) 1
• Acute target organ damage (stroke symptoms, chest pain, acute heart failure, acute kidney injury) 1

Your readings do not meet these criteria, so outpatient management is appropriate. 1

3. Essential Baseline Workup

Before or concurrent with treatment initiation, obtain: 2

• Serum creatinine and estimated glomerular filtration rate (eGFR) to assess kidney function 2
• Urine albumin-to-creatinine ratio to detect early kidney damage 2
• Fasting lipid panel and glucose to calculate 10-year cardiovascular disease risk 2
• 12-lead electrocardiogram to identify left ventricular hypertrophy or prior myocardial infarction 2
• Serum electrolytes (potassium, sodium) to screen for secondary causes like primary aldosteronism 1

4. Screen for Secondary Hypertension If:

• Sudden onset or worsening of hypertension 1
• Age <30 years requiring treatment 1
• Hypokalemia with normal/high sodium (suggests Conn's syndrome) 1
• Elevated serum creatinine, proteinuria, or hematuria 1
• Resistant to 3-drug regimen 1

Pharmacological Treatment Strategy

Start Combination Therapy Immediately

Begin with a two-drug fixed-dose single-pill combination containing: 1, 2, 3

• RAS blocker (ACE inhibitor like lisinopril OR angiotensin receptor blocker) 1, 2, 3, 4
• PLUS either a dihydropyridine calcium channel blocker (like amlodipine) 1, 2, 3, 5
• OR a thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1, 2, 3, 6

Rationale: With systolic BP ≥160 mmHg, monotherapy is inadequate—you require combination therapy from the start. 1, 3 Single-pill combinations improve adherence compared to separate pills. 1, 3

Escalation Plan If BP Remains ≥140/90 mmHg After 3 Months:

• Add a third agent to create triple therapy: RAS blocker + calcium channel blocker + thiazide-like diuretic, preferably as a single-pill combination. 1, 2, 3
• If still uncontrolled on triple therapy, add low-dose spironolactone (mineralocorticoid receptor antagonist) as fourth-line agent for resistant hypertension. 2, 7

Avoid These Pitfalls:

• Never combine two RAS blockers (ACE inhibitor + ARB together)—this is contraindicated. 3
• Do not use beta-blockers as first-line unless you have specific indications (angina, post-MI, heart failure with reduced ejection fraction, or atrial fibrillation requiring rate control). 3

Blood Pressure Targets

Target systolic BP: 120-129 mmHg if well tolerated, with diastolic BP <80 mmHg but not <70 mmHg to avoid organ hypoperfusion. 1, 2, 3

• If you have diabetes or chronic kidney disease with eGFR >30 mL/min/1.73m², the same target applies: 120-129 mmHg systolic. 3
• If you cannot tolerate this target due to symptoms (dizziness, fatigue), use the "as low as reasonably achievable" (ALARA) principle. 2, 3
• Achieve target BP within 3 months of treatment initiation. 1, 2

Lifestyle Modifications (Start Immediately)

These are not optional—they complement medication and may allow dose reduction: 1, 8

Weight Management

• Achieve and maintain BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women). 3, 8
• Weight loss of even 5-10 kg significantly reduces BP. 1, 8

Dietary Changes

• Adopt Mediterranean or DASH dietary pattern emphasizing fruits, vegetables, whole grains, fish, nuts, and olive oil. 2, 3, 8
• Restrict sodium to approximately 2 g/day (about 5 g salt/day)—eliminate table salt and avoid processed foods. 1, 2, 3, 8
• Increase potassium intake through diet (bananas, potatoes, leafy greens) unless you have kidney disease. 1, 8
• Reduce free sugar consumption, especially sugar-sweetened beverages. 3, 8
• Reduce saturated fat intake and replace with monounsaturated fats (olive oil, rapeseed oil). 1

Alcohol and Tobacco

• Limit alcohol to <100 g/week (approximately 7 standard drinks) or preferably avoid completely. 2, 3, 8
• Stop all tobacco use immediately and enroll in smoking cessation programs—tobacco independently increases cardiovascular mortality. 2, 3, 8

Physical Activity

• Engage in moderate-intensity aerobic exercise ≥150 minutes/week (brisk walking, cycling, swimming). 1, 2, 3, 8
• Add resistance training 2-3 times per week. 3, 8

Monitoring and Follow-Up

• Reassess BP and medication tolerance within 2-4 weeks of treatment initiation. 2
• See your physician every 1-3 months until BP is controlled. 1
• Use home BP monitoring for ongoing assessment and improved adherence—take readings at the same time daily and keep a log. 1, 2, 3
• Annual cardiovascular risk reassessment including lipid management and diabetes screening. 2
• Continue treatment lifelong if tolerated, even beyond age 85 years—do not discontinue prematurely. 2, 3

Why This Approach Matters

A 10 mmHg reduction in systolic BP decreases cardiovascular disease events by approximately 20-30%, including stroke, myocardial infarction, and cardiovascular death. 6 Your current readings place you at significantly elevated risk that requires immediate intervention to prevent these outcomes. 1, 6