I have a blood pressure of 155/84 mm Hg; what are the recommended next steps for evaluation and treatment?

Management of Blood Pressure 155/84 mmHg

Classification and Immediate Action

Your blood pressure of 155/84 mmHg represents Stage 2 hypertension and requires prompt initiation of both lifestyle modifications and antihypertensive medication. 1

• Stage 2 hypertension is defined as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg 1
• You should be evaluated by or referred to a primary care provider within 1 month of this diagnosis 1
• Immediate dual-drug therapy is recommended because your systolic pressure is ≥160 mmHg, which warrants prompt treatment with two antihypertensive agents from different classes 1, 2

Cardiovascular Risk Assessment Required

Before starting medication, your 10-year atherosclerotic cardiovascular disease (ASCVD) risk must be calculated using the ACC/AHA Pooled Cohort Equations 1:

• If you have diabetes or chronic kidney disease, you are automatically classified as high-risk and require aggressive treatment 1
• If your 10-year ASCVD risk is ≥10%, you need both lifestyle changes and dual-drug therapy immediately 1
• Even if your calculated risk is <10%, your systolic BP ≥160 mmHg mandates drug treatment 1, 2

Recommended Pharmacologic Treatment

Initial Dual Therapy (Start Immediately)

For non-Black patients: 1, 2

• Start an ACE inhibitor (e.g., lisinopril 10 mg daily) OR an ARB (e.g., losartan 50 mg daily) 1, 2
• PLUS a calcium channel blocker (e.g., amlodipine 5 mg daily) OR a thiazide-like diuretic (e.g., chlorthalidone 12.5–25 mg daily) 1, 2

For Black patients: 2

• Start a calcium channel blocker (e.g., amlodipine 5 mg daily) PLUS a thiazide-like diuretic (e.g., chlorthalidone 12.5–25 mg daily) 2
• ARBs or ACE inhibitors are less effective as monotherapy in Black patients but can be added as a third agent if needed 2

Preferred Medication Choices

• Chlorthalidone is preferred over hydrochlorothiazide due to its longer half-life (24–72 hours) and superior cardiovascular outcome data from the ALLHAT trial 1, 2
• Single-pill combination therapy is strongly recommended to improve medication adherence 1, 2

Blood Pressure Targets

• Primary target: <130/80 mmHg for most adults 1, 2
• Minimum acceptable target: <140/90 mmHg 1, 2
• Optimal target if well-tolerated: 120–129 mmHg systolic 1, 2
• Goal: Achieve target BP within 3 months of starting treatment 1, 2

Essential Lifestyle Modifications (Start Immediately)

These interventions can lower your BP by 10–20 mmHg and are mandatory alongside medication 1, 2:

• Sodium restriction to <2 g/day (approximately 5 g of salt): reduces systolic BP by 5–10 mmHg 2
• DASH diet (high in fruits, vegetables, whole grains, low-fat dairy; low in saturated fat): reduces BP by 11.4/5.5 mmHg 2
• Weight loss if overweight: losing 10 kg reduces BP by approximately 6.0/4.6 mmHg 2
• Regular aerobic exercise: ≥30 minutes most days (≥150 minutes/week) reduces BP by 4/3 mmHg 2
• Limit alcohol: ≤2 drinks/day for men, ≤1 drink/day for women 2

Monitoring Schedule

Initial Follow-Up (2–4 Weeks)

• Recheck blood pressure to assess medication response 1, 2
• Check serum potassium and creatinine 2–4 weeks after starting an ACE inhibitor, ARB, or diuretic 1, 2
• Assess for orthostatic hypotension, especially if you are older or have postural symptoms 1
• Confirm medication adherence 1

Ongoing Monitoring

• Repeat BP evaluation in 1 month after starting dual therapy 1
• Consider home BP monitoring (target <135/85 mmHg) to improve adherence and detect white-coat hypertension 1, 2
• If BP remains ≥140/90 mmHg after 1 month, add a third medication from a different class 1, 2

When to Escalate Treatment

If BP remains uncontrolled on dual therapy: 2

• Add a third agent to create triple therapy (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1, 2

If BP remains ≥140/90 mmHg on triple therapy: 2

• Add spironolactone 25–50 mg daily as the preferred fourth-line agent for resistant hypertension 2
• This provides additional BP reductions of 20–25/10–12 mmHg 2

Critical Pitfalls to Avoid

• Do not delay starting medication—your systolic BP ≥160 mmHg requires prompt treatment within 2–4 weeks to reduce cardiovascular risk 1, 2
• Do not start with monotherapy alone—dual therapy is recommended for Stage 2 hypertension 1, 2
• Do not combine an ACE inhibitor with an ARB—this increases risks of hyperkalemia and acute kidney injury without added cardiovascular benefit 1, 2
• Verify medication adherence before assuming treatment failure—non-adherence is the most common cause of apparent treatment resistance 2

Screening for Secondary Hypertension

If your BP remains severely elevated (≥180/110 mmHg) or resistant to triple therapy, screen for secondary causes 2, 3:

• Primary aldosteronism
• Renal artery stenosis
• Obstructive sleep apnea
• Pheochromocytoma
• Medication interference (NSAIDs, decongestants, oral contraceptives, systemic corticosteroids)