What is the step‑by‑step approach to managing hypertension, including lifestyle modifications, blood pressure targets, and first‑line medication selection and titration?

Stepwise Management of Hypertension

For patients with confirmed hypertension ≥140/90 mmHg, initiate lifestyle modifications immediately alongside prompt pharmacologic therapy with an ACE inhibitor or ARB as first-line treatment, escalating to multiple-drug therapy as needed to achieve target blood pressure <140/90 mmHg (or <130/80 mmHg in high-risk patients). 1

Blood Pressure Targets

• Standard target: <140/90 mmHg for most patients 1
• Intensive target: <130/80 mmHg for patients with diabetes, chronic kidney disease, established cardiovascular disease, or 10-year ASCVD risk ≥20% 1, 2
• Younger patients: Consider <130/80 mmHg if achievable without undue treatment burden 1
• Older patients (≥65 years) with diabetes: Target 130-139 mmHg systolic 2

Step 1: Lifestyle Modifications (Initiate for ALL patients with BP >120/80 mmHg)

• Weight loss: Target BMI 18.5-25 kg/m² if overweight 1, 2
• DASH-style diet: 8-10 servings of fruits/vegetables daily, 2-3 servings of low-fat dairy products daily 1
• Sodium restriction: <2,300 mg/day 1, 2
• Potassium increase: Through dietary sources 1, 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• Physical activity: 30-60 minutes of moderate activity >5 days/week 2

Step 2: Pharmacologic Therapy Initiation

Blood Pressure 140-159/90-99 mmHg (Stage 1)

• Start with single-drug therapy plus lifestyle modifications 1
• First-line choice: ACE inhibitor OR ARB 1
• Alternative first-line agents: thiazide-like diuretic or dihydropyridine calcium channel blocker 1

Blood Pressure ≥160/100 mmHg (Stage 2)

• Start with two-drug therapy or single-pill combination immediately 1
• Preferred combination: ACE inhibitor or ARB PLUS thiazide-like diuretic OR calcium channel blocker 1

Special Populations Requiring ACE Inhibitor or ARB First-Line

• Albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB at maximum tolerated dose 1
• Established coronary artery disease: ACE inhibitor or ARB recommended 1
• If one class not tolerated: Substitute with the other 1

Step 3: Titration and Addition of Second/Third Agents

• Multiple-drug therapy is generally required to achieve BP targets 1

• Typical sequence for adding agents:

  1. ACE inhibitor or ARB (first-line)
  2. Thiazide-like diuretic (second agent)
  3. Dihydropyridine calcium channel blocker (third agent) 1

• Titrate each medication to maximum tolerated dose before adding another agent 1

Critical Contraindications

• Never combine ACE inhibitor + ARB (increased risk of hyperkalemia, syncope, acute kidney injury) 1
• Never combine ACE inhibitor or ARB + direct renin inhibitor 1

Step 4: Resistant Hypertension (BP ≥140/90 mmHg on 3+ drugs)

• Definition: Uncontrolled BP despite appropriate lifestyle measures plus diuretic and two other antihypertensive drugs at adequate doses 1

• Before diagnosing resistant hypertension, exclude:

  • Medication nonadherence (address cost, side effects)
  • White coat hypertension
  • Secondary hypertension causes 1

• Fourth-line agent: Add mineralocorticoid receptor antagonist (spironolactone) 1

• Spironolactone is effective even without biochemical evidence of aldosterone excess 1

Monitoring Requirements

• Blood pressure: Measure at every routine visit; confirm elevated readings on separate day 1, 2
• Laboratory monitoring (if on ACE inhibitor, ARB, or diuretic):
  • Serum creatinine/eGFR: at least annually 1
  • Serum potassium: at least annually 1
  • Recheck 2-4 weeks after initiating therapy 1

Special Circumstances

Pregnancy with Chronic Hypertension

• Target BP: 110-129/65-79 mmHg 1, 2
• Absolute contraindication: ACE inhibitors and ARBs 1, 2

Hypertensive Emergency (BP ≥180/120 mmHg with end-organ damage)

• Immediate ICU admission required 3
• Use short-acting IV titratable agents: labetalol, esmolol, fenoldopam, nicardipine, or clevidipine 3
• Avoid: immediate-release nifedipine, hydralazine 3
• Reduce BP within hours to prevent further organ damage 3

Hypertensive Urgency (BP ≥180/120 mmHg without end-organ damage)

• Outpatient management with oral antihypertensives 3
• Reduce BP over days, not hours 3

Common Pitfalls to Avoid

• Clinical inertia: Failure to promptly initiate or titrate therapy when BP remains above goal 1
• Monotherapy persistence: Not advancing to multiple-drug therapy when single agent fails 1
• Inadequate dosing: Adding new agents before maximizing current medications 1
• Ignoring lifestyle modifications: Pharmacotherapy alone is less effective 1, 4
• Inappropriate drug combinations: ACE inhibitor + ARB increases harm without benefit 1