How should I diagnose and manage primary hypertension in an adult patient without secondary causes or compelling comorbidities?

Diagnosis and Management of Primary Hypertension in Adults

Diagnosis and Confirmation

Hypertension is diagnosed when the average of two properly measured office readings shows systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg, according to the 2017 ACC/AHA guidelines. 1

Proper Blood Pressure Measurement Technique

• The patient must be seated with back support for >5 minutes, with no caffeine, exercise, or smoking for ≥30 minutes prior, empty bladder, appropriate cuff size covering ≥80% of arm circumference, arm at heart level, and averaging 2-3 readings taken 1-2 minutes apart. 1
• If the initial office reading is elevated, repeat the measurement twice and use the average of those final two readings to determine the BP category. 2
• Automated oscillometric devices provide repeated measurements without a provider present, minimizing white coat effect. 1

Confirming the Diagnosis

• Obtain home BP monitoring or 24-hour ambulatory BP monitoring to exclude white coat hypertension (present in 20-30% of apparent hypertension cases) and to confirm true uncontrolled status. 1, 3
• Measure BP change from seated to standing position; a decline >20 mm Hg systolic or >10 mm Hg diastolic after 1 minute indicates orthostatic hypotension. 1

Initial Laboratory Evaluation

All newly diagnosed hypertensive patients require baseline laboratory testing to assess cardiovascular risk, screen for target organ damage, and exclude secondary causes. 1

Required Baseline Tests

• Fasting blood glucose (or HbA1c if elevated) 1
• Complete blood count 1
• Lipid profile (total cholesterol, LDL, HDL, triglycerides) 1
• Serum creatinine with estimated GFR 1
• Serum sodium, potassium, and calcium 1
• Thyroid-stimulating hormone 1
• Urinalysis with urine albumin-to-creatinine ratio 1
• 12-lead electrocardiogram to detect left ventricular hypertrophy, arrhythmias, or ischemic changes 1

Optional Tests for Risk Stratification

• Echocardiography if ECG is abnormal, cardiac symptoms are present, or to detect subclinical left ventricular dysfunction 1
• Uric acid 1

Lifestyle Modifications (Foundation of Treatment)

Lifestyle modifications are mandatory for all hypertensive patients and should be implemented before or alongside pharmacotherapy. 1

Dietary Interventions

• Adopt the DASH (Dietary Approaches to Stop Hypertension) diet, which is the most effective dietary modification for lowering BP. 2 This includes increased fruits, vegetables, and low-fat dairy products. 4
• Restrict sodium intake to <2,400 mg/day (ideally <1,500 mg/day for greater BP reduction). 1, 3

Weight and Physical Activity

• Achieve weight loss in overweight patients (BMI ≥30 kg/m² is a robust risk factor for uncontrolled hypertension). 3, 4
• Increase physical activity with regular aerobic exercise. 1, 4

Alcohol and Tobacco

• Limit alcohol consumption to ≤2 drinks/day for men and ≤1 drink/day for women; those consuming ≥3 drinks/day who reduce intake by 50% experience average SBP/DBP reductions of approximately 5.5/4.0 mm Hg. 1
• Counsel on smoking cessation. 3

Pharmacological Treatment

When to Initiate Drug Therapy

• For patients with confirmed hypertension (BP ≥130/80 mm Hg) and 10-year ASCVD risk ≥10%, or with BP ≥140/90 mm Hg regardless of cardiovascular risk, initiate pharmacological treatment. 1
• For patients with BP 130-139/80-89 mm Hg and lower cardiovascular risk, attempt lifestyle modifications for 3-6 months before adding medication. 3

First-Line Medication Classes

Initial pharmacotherapy should include one or more of the following four drug classes: 2

1. ACE inhibitor (angiotensin-converting enzyme inhibitor)
2. ARB (angiotensin receptor blocker)
3. Dihydropyridine calcium channel blocker (preferably amlodipine)
4. Thiazide or thiazide-like diuretic (preferably chlorthalidone or indapamide over hydrochlorothiazide)

1, 3

Combination Therapy Strategy

• Two-drug combination therapy is recommended as initial treatment for most patients, preferably as a single-pill combination to improve adherence. 3
• The preferred combinations are: RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or a thiazide-like diuretic. 3
• Never combine two RAS blockers (ACE inhibitor plus ARB). 3

Medication Adherence

• Use once-daily dosing and combination pills to improve adherence (up to 25% of patients don't fill their initial prescription, and only 1 in 5 has sufficiently high adherence). 1, 3

Blood Pressure Targets

The target BP for most adults is <130/80 mm Hg. 1

Special Populations

• For noninstitutionalized, ambulatory, community-dwelling adults ≥65 years with average SBP ≥130 mm Hg, the treatment goal is SBP <130 mm Hg, provided treatment is well tolerated. 1
• For older adults (≥65 years) with high burden of comorbidity and limited life expectancy, use clinical judgment, patient preference, and a team-based approach to determine intensity of BP lowering. 1
• Intensive BP control (systolic <120 mm Hg) decreases atherosclerotic cardiovascular disease and all-cause mortality in patients with elevated cardiovascular risk, but increases adverse effects including hypotension, electrolyte abnormalities, acute kidney injury, and syncope. 2

Follow-Up and Monitoring

• Once BP is controlled and stable, follow up yearly for BP monitoring and cardiovascular risk factor assessment. 3
• Monitor serum sodium and potassium during diuretic or RAS blocker titration. 1
• Monitor serum creatinine and urinary albumin as markers of chronic kidney disease progression. 1

Team-Based Care and Quality Improvement

• Implement a team-based care approach with use of electronic health records, patient registries, and telehealth strategies to improve hypertension control. 1, 3
• Every adult with hypertension should have an evidence-based care plan that promotes treatment goals, self-management, effective management of comorbid conditions, and timely follow-up. 1

Common Pitfalls to Avoid

• Failing to use proper BP measurement technique leads to misclassification and inappropriate treatment decisions. 1, 3
• Not confirming the diagnosis with home or ambulatory BP monitoring results in overtreatment of white coat hypertension. 1, 3
• Using hydrochlorothiazide instead of chlorthalidone or indapamide provides inferior BP control. 1, 3
• Underestimating medication non-adherence—always assess for missed doses, side effects, and cost barriers. 1, 3
• Overlooking interfering substances: NSAIDs, decongestants, stimulants, oral contraceptives, cyclosporine, erythropoietin, licorice, and ephedra can all elevate BP. 1, 3