What is the recommended management of hypertension in an adult patient without contraindications, including target seated blood pressure, lifestyle modifications, and first‑line medication choices?

Blood Pressure Management in Adults Without Contraindications

Target Blood Pressure

For most adults without contraindications, target a seated blood pressure <130/80 mmHg, with a minimum acceptable goal of <140/90 mmHg. 1

• For adults ≥65 years, target systolic BP <130 mmHg if tolerated, though <140/90 mmHg is acceptable minimum 1
• The 2024 ESC guidelines recommend an optimal systolic target of 120-129 mmHg when well tolerated 1
• For patients 80+ years with high comorbidity burden or limited life expectancy, clinical judgment should guide intensity, but treatment should not be withheld based on age alone 1

Lifestyle Modifications (First-Line for All Patients)

Lifestyle interventions provide additive blood pressure reductions of 10-20 mmHg systolic and should be implemented immediately alongside or before pharmacotherapy. 1, 2

• Sodium restriction to <2 g/day yields 5-10 mmHg systolic reduction 1, 2
• DASH dietary pattern (high in fruits, vegetables, whole grains, low-fat dairy; low in saturated fat) reduces BP by approximately 11.4/5.5 mmHg 1, 2
• Weight loss of ~10 kg in overweight/obese patients decreases BP by roughly 6.0/4.6 mmHg 1, 2
• Regular aerobic exercise (≥30 minutes most days, ~150 minutes/week moderate intensity) lowers BP by ~4/3 mmHg 1, 2
• Alcohol limitation to ≤2 drinks/day for men and ≤1 drink/day for women 1, 2
• Potassium supplementation (0.5-1.0 g/day increase through diet or potassium-enriched salt) should be considered in patients without CKD or potassium-sparing medications 1

First-Line Pharmacotherapy

For stage 1 hypertension (140-159/90-99 mmHg), initiate a single agent from one of four first-line classes: thiazide-type diuretic, ACE inhibitor, ARB, or calcium channel blocker. 1, 2

Preferred Initial Agents by Population:

• General population (non-Black): ACE inhibitor, ARB, thiazide-type diuretic, or calcium channel blocker are all acceptable 1, 2
• Black patients: Thiazide-type diuretic or calcium channel blocker preferred over ACE inhibitor/ARB 1
• Patients with diabetes or CKD: ACE inhibitor or ARB preferred, especially with albuminuria 1

Specific Drug Recommendations:

• Thiazide-type diuretics: Chlorthalidone 12.5-25 mg daily is preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes data 1, 3
• ACE inhibitors: Lisinopril 10-40 mg daily or enalapril 5-40 mg daily 2
• ARBs: Losartan 50-100 mg daily or candesartan 8-32 mg daily 2
• Calcium channel blockers: Amlodipine 5-10 mg daily 1, 2

Stage 2 Hypertension (≥160/100 mmHg)

For stage 2 hypertension, initiate two-drug combination therapy immediately, preferably as a single-pill combination to improve adherence. 1

• Recommended combinations: thiazide-type diuretic + ACE inhibitor/ARB, or thiazide-type diuretic + calcium channel blocker, or ACE inhibitor/ARB + calcium channel blocker 1
• Single-pill combinations are strongly favored because they significantly improve medication adherence and persistence 1

Escalation to Triple Therapy

If BP remains ≥140/90 mmHg despite dual therapy at optimal doses, add a third agent to create the standard triple regimen: ACE inhibitor or ARB + calcium channel blocker + thiazide-type diuretic. 1, 3

• This combination targets three complementary mechanisms: renin-angiotensin system blockade, vasodilation, and volume reduction 1, 3
• Triple therapy achieves BP control in >80% of patients 3

Resistant Hypertension (Fourth-Line Therapy)

If BP remains ≥140/90 mmHg despite optimized triple therapy, add spironolactone 25-50 mg daily as the preferred fourth-line agent. 1, 3

• Spironolactone provides additional reductions of approximately 20-25/10-12 mmHg systolic/diastolic 1, 3
• Monitor serum potassium and creatinine 2-4 weeks after initiation due to hyperkalemia risk, especially when combined with ACE inhibitor/ARB 1, 3
• Alternative fourth-line agents if spironolactone contraindicated: amiloride, doxazosin, eplerenone, or clonidine 1, 4

Monitoring and Follow-Up

• Confirm diagnosis with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before initiating or escalating therapy 1
• Reassess BP 2-4 weeks after any medication change 1, 3
• Goal: achieve target BP within 3 months of initiating or modifying therapy 1
• Check serum potassium and creatinine 2-4 weeks after starting ACE inhibitor, ARB, or diuretic 1, 3
• Annual follow-up once BP is controlled and stable 1

Critical Pitfalls to Avoid

• Do not combine ACE inhibitor with ARB (dual RAS blockade increases hyperkalemia and acute kidney injury risk without cardiovascular benefit) 1
• Do not add beta-blocker as second or third agent unless compelling indication exists (angina, post-MI, heart failure with reduced ejection fraction, atrial fibrillation) 1
• Do not delay treatment intensification when BP remains ≥140/90 mmHg; prompt action within 2-4 weeks reduces cardiovascular risk 1, 3
• Do not assume treatment failure without first confirming medication adherence and excluding interfering substances (NSAIDs, decongestants, oral contraceptives, systemic corticosteroids) 1, 3
• Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with left ventricular dysfunction or heart failure 1, 3

When to Screen for Secondary Hypertension

Screen for secondary causes when BP is severely elevated (≥180/110 mmHg), resistant to triple therapy, or in adults <40 years without obesity. 1

• Evaluate for primary aldosteronism (renin and aldosterone measurements should be considered in all adults with confirmed hypertension ≥140/90 mmHg) 1
• Assess for renal artery stenosis, obstructive sleep apnea, and pheochromocytoma in appropriate clinical contexts 1, 3