What is the recommended management, including lifestyle and medication, for an adult with hypertension (blood pressure ≥130/80 mm Hg), considering race, diabetes, chronic kidney disease, and age?

Management of Hypertension in Adults

For adults with confirmed hypertension (BP ≥130/80 mm Hg), initiate lifestyle modifications immediately for all patients, and add pharmacologic therapy at BP ≥130/80 mm Hg for those with diabetes, chronic kidney disease, or cardiovascular disease, or at BP ≥140/90 mm Hg for lower-risk patients without these conditions. 1

Blood Pressure Targets

Target BP <130/80 mm Hg for most adults with hypertension, regardless of cardiovascular risk level. 1

• For patients with diabetes: Target BP <130/80 mm Hg 1
• For patients with chronic kidney disease: Target BP <130/80 mm Hg 1
• Older adults (≥65 years): Target systolic BP <130 mm Hg if tolerated 2

Lifestyle Modifications (Required for All Patients)

Implement the following lifestyle changes at the time of diagnosis, not as a trial period before medication: 1, 2

• Weight reduction: Achieve BMI 20-25 kg/m² 2
• DASH diet: Consume 8-10 servings of fruits and vegetables daily, 2-3 servings of low-fat dairy products, reduce saturated fat to <7% of calories 1, 2
• Sodium restriction: Limit intake to <2 g/day (approximately 5 g salt or <2,300 mg sodium) 1, 2
• Alcohol moderation: Maximum 2 drinks/day for men, 1 drink/day for women 1
• Physical activity: Regular aerobic exercise 1, 2
• Smoking cessation: Complete cessation with no exposure to secondhand smoke 1

Pharmacologic Treatment Algorithm

When to Start Medication

Stage 1 Hypertension (130-139/80-89 mm Hg):

• High-risk patients (diabetes, CKD, or 10-year ASCVD risk ≥10%): Start medication immediately 1
• Lower-risk patients (no diabetes, CKD, or 10-year ASCVD risk <10%): Start medication if BP remains ≥140/90 mm Hg 1

Stage 2 Hypertension (≥140/90 mm Hg):

• Start medication immediately for all patients 1
• If BP ≥160/100 mm Hg: Start with 2 antihypertensive agents from different classes 1

First-Line Medication Selection

General Population (without compelling indications):

• Preferred: Thiazide-type diuretics (chlorthalidone 12.5-25 mg/day preferred over hydrochlorothiazide 25-50 mg/day) or calcium-channel blockers 1
• Alternative: ACE inhibitors or angiotensin-receptor blockers 1

Black Patients (including those with diabetes):

• First-line: Thiazide-type diuretics or calcium-channel blockers 1
• Rationale: ACE inhibitors and ARBs are less effective at lowering BP in black patients when used as monotherapy 1
• Exception: Use ACE inhibitor or ARB if CKD with proteinuria is present 1

Patients with Diabetes:

• First-line: ACE inhibitor or ARB if coronary artery disease or albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g) is present 1
• Alternative: Thiazide-type diuretic or calcium-channel blocker if no albuminuria 1
• Target BP <130/80 mm Hg 1

Patients with Chronic Kidney Disease:

• First-line: ACE inhibitor or ARB, especially if proteinuria present 1, 3, 4
• These agents reduce proteinuria beyond their BP-lowering effects 3, 4
• Continue ACE inhibitor or ARB even as eGFR declines to <30 mL/min/1.73 m² for cardiovascular benefit 1
• Monitor serum creatinine/eGFR and potassium 2-4 weeks after initiation 1, 2

Combination Therapy

Most patients require 2 or more medications to achieve BP target <130/80 mm Hg. 1

• For BP ≥160/100 mm Hg: Initiate 2 agents from different classes simultaneously 1
• Effective combinations: ACE inhibitor or ARB + calcium-channel blocker or thiazide diuretic 5
• For resistant hypertension (BP ≥140/90 mm Hg on 3 agents including a diuretic): Add mineralocorticoid receptor antagonist 1

Race-Specific Considerations

Black Patients:

• Higher prevalence of severe hypertension and greater risk of stroke (1.8x), heart failure (1.5x), and end-stage renal disease (4.2x) compared to white patients 1
• Require more aggressive treatment with 2 or more medications to achieve target 1
• Thiazide-type diuretics (chlorthalidone) and calcium-channel blockers are superior for BP reduction and cardiovascular outcomes 1

Hispanic/Latino Patients:

• Lower awareness and treatment rates than white and black patients 1
• Cardiovascular risk varies by ancestry (Caribbean origin has higher risk than Mexican/Central American origin) 1
• Apply same treatment principles as general population 1

Asian Patients:

• Limited specific data, but BP reduction effects may be greater than in white patients 6
• Apply same treatment principles as general population 1

Age-Specific Considerations

Older Adults (≥65 years):

• Target systolic BP <130 mm Hg if tolerated 2
• Monitor for orthostatic hypotension at each visit 1
• Assess for postural symptoms before dose adjustments 1

Younger Adults (<40 years):

• Screen for secondary causes of hypertension if BP ≥140/90 mm Hg confirmed 2
• Measure renin and aldosterone levels to screen for primary aldosteronism 2

Monitoring and Follow-Up

Initial Phase:

• Reassess BP 2-4 weeks after initiating or adjusting therapy 1, 2
• Monitor electrolytes and renal function 2-4 weeks after starting ACE inhibitor, ARB, or diuretic 1, 2
• Continue monthly evaluation until BP target achieved 1

Maintenance Phase:

• Once BP controlled and stable, follow up at least yearly 2
• Consider home BP monitoring (target <135/85 mm Hg) or 24-hour ambulatory monitoring (target <130/80 mm Hg) to exclude white coat hypertension 2

Adjunctive Cardiovascular Risk Reduction

Statin Therapy:

• Initiate statin for patients with 10-year ASCVD risk ≥10% (includes all patients with diabetes, CKD, or age ≥65 years) 5
• Target LDL-C <70 mg/dL for very high-risk patients (hypertension + CVD/CKD/diabetes) 5
• Start statins concurrently with antihypertensive therapy in high-risk patients 5

Aspirin:

• Use 75-160 mg daily for patients age ≥50 years with BP controlled to <150/90 mm Hg and 10-year CHD risk ≥10% 1

Common Pitfalls to Avoid

• Do not delay medication in high-risk patients (diabetes, CKD, CVD) for a trial of lifestyle modification alone—start both simultaneously 1
• Do not use β-blockers as first-line agents unless specific indication (prior MI, active angina, heart failure with reduced ejection fraction) 1
• Do not underdose thiazide diuretics: Use chlorthalidone 12.5-25 mg/day or hydrochlorothiazide 25-50 mg/day for proven cardiovascular benefit 1
• Do not use ACE inhibitors or ARBs as monotherapy in black patients without CKD/proteinuria—combine with thiazide or calcium-channel blocker 1
• Do not ignore white coat hypertension: Confirm diagnosis with home or ambulatory monitoring before committing to lifelong therapy 2
• Do not forget to screen for secondary hypertension in patients <40 years or with resistant hypertension 2