I have a blood pressure of 181/100 mm Hg and have not seen a healthcare professional in three years; what evaluation and treatment are recommended?

Immediate Evaluation and Treatment for Blood Pressure 181/100 mmHg

You need to see a healthcare provider within 1 week to start combination antihypertensive therapy with two medications from different classes, along with lifestyle modifications, because your blood pressure qualifies as Stage 2 hypertension requiring prompt treatment to prevent cardiovascular complications. 1

Urgency Assessment

Your blood pressure of 181/100 mmHg does not automatically constitute a hypertensive emergency, but it requires prompt evaluation. 2 The critical distinction is whether you have symptoms of acute target-organ damage:

• If you have chest pain, severe headache, shortness of breath, vision changes, confusion, or neurological symptoms → go to the emergency department immediately for evaluation of hypertensive emergency 2, 3
• If you are asymptomatic (which appears to be your case) → this is Stage 2 hypertension requiring outpatient treatment initiation within 1 week, not an emergency 1, 2

A common pitfall is treating asymptomatic severe hypertension too aggressively in the emergency department, which can cause harmful rapid blood pressure drops and ischemic complications. 2

Confirmation Before Treatment

Before starting medication, your diagnosis should ideally be confirmed with out-of-office blood pressure monitoring (home or ambulatory monitoring) to exclude white-coat hypertension. 2, 4, 5 However, given your blood pressure is ≥160/100 mmHg, the 2024 ESC guidelines recommend you can proceed with immediate treatment after confirming the elevated reading with 2-3 additional measurements during the same visit. 4

Since you haven't seen a doctor in 3 years, you should obtain home blood pressure measurements over the next few days while scheduling your appointment, but do not delay treatment beyond 1 week. 1

Required Initial Evaluation

When you see your healthcare provider, the following baseline tests are mandatory before starting antihypertensive medication: 2, 4

• Laboratory tests: Basic metabolic panel (creatinine, electrolytes), fasting glucose or HbA1c, lipid profile, urinalysis with albumin-to-creatinine ratio 2, 4
• Electrocardiogram to assess for left ventricular hypertrophy 2, 4
• 10-year cardiovascular risk calculation using the ASCVD calculator 2, 4
• Assessment for secondary hypertension causes if you have features like young age (<30 years), resistant hypertension, spontaneous low potassium, or symptoms of pheochromocytoma 5

Treatment Plan

Pharmacological Therapy

You require immediate initiation of two antihypertensive medications from different classes because Stage 2 hypertension (≥160/100 mmHg) mandates combination therapy. 1

First-line medication options include: 1, 2, 6

• Thiazide or thiazide-like diuretic (chlorthalidone 12.5-25 mg daily is preferred over hydrochlorothiazide due to longer half-life and proven cardiovascular benefit) 1, 2
• ACE inhibitor (e.g., lisinopril 10 mg daily, enalapril 5 mg daily) or ARB (e.g., losartan 50 mg daily, candesartan 8 mg daily) 1, 7, 6
• Calcium channel blocker (e.g., amlodipine 5 mg daily) 1, 6

Recommended initial combination: Start with a thiazide diuretic (chlorthalidone 12.5 mg) plus either an ACE inhibitor (lisinopril 10 mg) or calcium channel blocker (amlodipine 5 mg). 1, 2 If you are Black, initial therapy should be a calcium channel blocker plus thiazide diuretic. 8

Critical contraindications to avoid: 1

• Never combine an ACE inhibitor with an ARB 1, 2
• Avoid ACE inhibitors/ARBs if you have history of angioedema 1
• Avoid ACE inhibitors/ARBs if you are pregnant or planning pregnancy 1

Lifestyle Modifications (Start Immediately)

These should begin now, even before your appointment: 2, 4, 6

• Sodium restriction: Limit to <1,500 mg/day (less than one teaspoon of salt daily); avoid processed foods and do not add salt at the table 2, 4
• Potassium increase: Aim for 3,500-5,000 mg/day through diet (bananas, spinach, avocado) or potassium-enriched salt substitutes 2, 4
• Physical activity: 90-150 minutes per week of moderate-intensity aerobic exercise (brisk walking, jogging, cycling) 2, 4
• Weight loss: If overweight or obese 2, 6
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 2
• DASH diet: Emphasize fruits, vegetables, whole grains, lean proteins, low-fat dairy 6, 9

Monitoring Schedule

• Electrolytes and renal function: Recheck 2-4 weeks after starting ACE inhibitor, ARB, or diuretic 1, 2
• Blood pressure reassessment: Monthly until target is achieved 1, 2
• Target blood pressure: <130/80 mmHg if you are under 65 years old; systolic <130 mmHg if 65 or older 2, 6
• Ongoing monitoring: Once stable, check electrolytes and creatinine every 3-6 months 2

Critical Pitfalls to Avoid

• Do not delay treatment beyond 1 week thinking you can control this with lifestyle changes alone—your blood pressure is too high and requires medication 1
• Do not go to the emergency department unless you develop symptoms of organ damage, as asymptomatic severe hypertension should be managed outpatient 2, 3
• Do not accept monotherapy—Stage 2 hypertension requires two medications from the start 1
• Do not skip the baseline laboratory tests—they are essential for safe medication selection and monitoring 2, 4