How should I manage a patient with stage 2 hypertension (blood pressure 143/97 mm Hg) to lower the diastolic pressure?

Management of Blood Pressure 143/97 mmHg

You should immediately initiate combination therapy with two antihypertensive medications from different drug classes, specifically a thiazide-like diuretic (chlorthalidone or indapamide preferred) plus either an ACE inhibitor, ARB, or dihydropyridine calcium channel blocker, targeting a blood pressure goal of <130/80 mmHg. 1, 2

Classification and Urgency

• Your blood pressure of 143/97 mmHg represents stage 2 hypertension (BP ≥140/90 mmHg), which mandates prompt pharmacological intervention within one month alongside lifestyle modifications 1
• This level does not constitute a hypertensive emergency (which would be ≥180/110 mmHg with acute organ damage), but requires timely treatment initiation to reduce cardiovascular risk 2
• Confirm the diagnosis using out-of-office blood pressure monitoring (home or ambulatory BP monitoring) as soon as possible, ideally within one month 1, 2

Pharmacological Treatment Strategy

Initial Dual Therapy Approach

Start with two medications immediately rather than monotherapy, as stage 2 hypertension typically requires multiple agents to achieve control, and combination therapy achieves blood pressure goals more rapidly 1, 3

Medication Selection by Patient Characteristics

For non-Black patients without specific comorbidities:

• First choice: Thiazide-like diuretic (chlorthalidone 12.5-25 mg or indapamide 1.25-2.5 mg) + ACE inhibitor (e.g., lisinopril 10-20 mg) 1, 3
• Alternative: Thiazide-like diuretic + ARB (e.g., losartan 50 mg) 1, 4
• Alternative: Thiazide-like diuretic + dihydropyridine calcium channel blocker (e.g., amlodipine 5-10 mg) 1

For Black patients:

• First choice: Thiazide-like diuretic + dihydropyridine calcium channel blocker, as ACE inhibitors and ARBs are less effective as monotherapy in Black patients 1, 3

Special considerations:

• If diabetes with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g): Include an ACE inhibitor or ARB for renal protection 1, 2, 3
• If chronic kidney disease: Include an ACE inhibitor or ARB to improve kidney outcomes 1
• If coronary artery disease: Include an ACE inhibitor or ARB 3

Why Chlorthalidone Over Hydrochlorothiazide

• Chlorthalidone and indapamide are preferred over hydrochlorothiazide because they lower blood pressure more effectively (particularly at night), have longer therapeutic half-lives, and have stronger cardiovascular disease risk reduction data 3

Single-Pill Combinations

• Strongly prefer fixed-dose single-pill combinations when available, as they improve adherence, simplify the regimen, and produce greater blood pressure reduction at lower doses of component agents with fewer side effects 1, 3

Blood Pressure Goals

Target blood pressure <130/80 mmHg as the optimal goal for most adults, with a minimum acceptable target of <140/90 mmHg 1, 2

More specific targets based on age:

• If you are <65 years old: Aim for systolic BP 120-129 mmHg if well tolerated 1, 2, 3
• If you are ≥65 years old: Target systolic BP 130-139 mmHg 1, 2
• Diastolic BP target: <80 mmHg for all patients 1

Achieve target blood pressure within 3 months of treatment initiation 2, 3

Dose Titration Strategy

• Reassess blood pressure within 1 month after initiating therapy to evaluate response 1, 2, 3
• If blood pressure remains above target with two drugs, increase to full doses of both medications before adding a third agent 3
• If still uncontrolled with two drugs at full doses, escalate to a three-drug combination (typically ACE inhibitor or ARB + calcium channel blocker + thiazide diuretic) 1
• Slower dose escalation (every 6 weeks) provides higher blood pressure control rates and fewer serious adverse events than rapid escalation (every 2 weeks) 5

Resistant Hypertension Management

If blood pressure is not controlled with a three-drug combination:

• Add spironolactone 25-50 mg daily as the fourth agent 1
• If spironolactone not tolerated, consider eplerenone 1
• Alternatively, add a beta-blocker if not already indicated, then consider centrally acting agents, alpha-blockers, hydralazine, or other potassium-sparing diuretics 1

Lifestyle Modifications (Essential Alongside Medications)

Implement these evidence-based interventions immediately:

Dietary Changes

• Adopt a DASH or Mediterranean diet pattern: high in vegetables, fresh fruits, fish, nuts, unsaturated fatty acids (olive oil), and low-fat dairy products with low consumption of red meat 1, 2, 3
• Restrict sodium intake to approximately 2 g/day (equivalent to 5 g of salt/day) 1, 2
• Increase potassium intake through diet 6
• Consider salt substitutes (potassium-enriched), which can reduce systolic BP by approximately 9 mmHg and diastolic BP by 4 mmHg in stage 2 hypertension 7

Alcohol Restriction

• Men: <14 units/week (approximately 100 g/week of pure alcohol) 1
• Women: <8 units/week 1
• Ideally, avoid alcohol completely for best health outcomes 1

Weight Management

• Target BMI 20-25 kg/m² 3
• Target waist circumference <94 cm (men) or <80 cm (women) 1, 3

Physical Activity

• Engage in 150 minutes/week of moderate-intensity aerobic exercise plus resistance training 2-3 times/week 3

Tobacco Cessation

• Stop smoking immediately, as the cardiovascular risk reduction from smoking cessation outweighs the benefit of blood pressure reduction alone 1, 2

Monitoring and Follow-Up

• Repeat blood pressure evaluation in 1 month after initiating treatment 1, 2, 3
• Use home blood pressure monitoring or repeat ambulatory blood pressure monitoring to confirm office readings and detect white-coat or masked hypertension 1, 2
• Monitor serum creatinine, eGFR, and potassium levels at least annually, or more frequently if on ACE inhibitor, ARB, or diuretic 2
• Assess for target organ damage including left ventricular hypertrophy, proteinuria/albuminuria, and renal function 3

Common Pitfalls to Avoid

• Do not delay pharmacological treatment while attempting lifestyle modifications alone in stage 2 hypertension—both should be initiated simultaneously 1, 2
• Do not start with monotherapy in stage 2 hypertension, as most patients require two agents to achieve control 1, 3
• Do not use hydrochlorothiazide when chlorthalidone or indapamide are available, as they are more effective 3
• Do not escalate doses too rapidly (faster than every 4-6 weeks), as this increases serious adverse events without improving control rates 5
• Do not ignore diastolic BP even if systolic BP reaches target—diastolic BP should also be <80 mmHg 1