What is the algorithm for managing hypertension?

From the Guidelines

The hypertension treatment algorithm should begin with lifestyle modifications and a target blood pressure of <120 mmHg, as recommended by the KDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease 1. The algorithm should include lifestyle modifications for all patients, such as weight loss, regular exercise, reduced sodium intake, limited alcohol consumption, and a DASH diet.

• If blood pressure remains above 140/90 mmHg, medication therapy should be initiated with first-line medications including thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers.
• For patients with chronic kidney disease (CKD), the use of renin-angiotensin system inhibitors (RASi) is recommended, as they have been shown to reduce the risk of kidney failure and major cardiovascular events 1.
• The choice of antihypertensive medication should be individualized based on the patient's comorbidities, age, and other factors, with a goal of achieving a blood pressure of <120 mmHg.
• Regular monitoring of blood pressure is crucial, and combination therapy may be necessary to achieve optimal blood pressure control.
• The use of telehealth strategies, such as telemedicine and mobile health interventions, may also be beneficial in managing patients with hypertension, as they have been shown to reduce systolic blood pressure in patients with hypertension 1.

From the FDA Drug Label

INDICATIONS & USAGE 1. 1 Hypertension Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

The hypertension treatment algorithm involves:

• Lowering blood pressure to reduce the risk of fatal and non-fatal cardiovascular events
• Comprehensive cardiovascular risk management, including:
  • Lipid control
  • Diabetes management
  • Antithrombotic therapy
  • Smoking cessation
  • Exercise
  • Limited sodium intake
• Using more than one drug to achieve blood pressure goals, if necessary
• Following published guidelines, such as those of the JNC 2

From the Research

Hypertension Algorithm

The management of hypertension involves a combination of lifestyle modifications and pharmacological interventions.

• Lifestyle modifications are recommended as the first-line strategy to prevent and control hypertension in adulthood 3, 4, 5, 6.
• These modifications include:
  • Maintaining a healthy body weight
  • Increased levels of physical activity
  • Healthy eating and drinking
  • Avoidance and cessation of smoking and alcohol use
  • Management of stress and sleep levels
• Specific dietary recommendations include:
  • Sodium restriction
  • Increased consumption of potassium, calcium, and magnesium
  • Adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan
• Pharmacological interventions may be necessary for patients who do not respond to lifestyle modifications or have severe hypertension 7.
• The choice of antihypertensive medication depends on various factors, including the patient's medical history, lifestyle, and preferences.
• Combination therapy with angiotensin receptor blockers (ARBs) and calcium channel blockers may be effective for patients with uncontrolled hypertension 7.

Lifestyle Interventions

Lifestyle interventions can be effective in preventing and treating hypertension.

• Regular physical exercise, body weight management, and healthy dietary patterns have been shown to have preventive and antihypertensive effects 6.
• Stress management and promotion of adequate sleep patterns coupled with circadian entrainment may also be beneficial 6.
• The physiological mechanisms underlying the beneficial effects of lifestyle interventions on hypertension include:
  • Prevention of traditional risk factors such as obesity and insulin resistance
  • Improvements in vascular health through an improved redox and inflammatory status
  • Reduced sympathetic overactivation
  • Increased secretion of myokines

Clinical Guidelines

Clinical guidelines recommend lifestyle modifications as the first-line strategy for preventing and controlling hypertension.

• The International Society of Hypertension, the World Hypertension League, and the European Society of Hypertension endorse lifestyle management recommendations 3.
• The Canadian Hypertension Society, the Canadian Coalition for High Blood Pressure Prevention and Control, and the Heart and Stroke Foundation of Canada also recommend lifestyle modifications 4.
• The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) provides guidelines for lifestyle modification components 5.