How should I manage hypertension in a primary‑care clinic?

Management of Hypertension in Primary Care

Screen all adults routinely for hypertension using proper measurement technique, diagnose using the 130/80 mm Hg threshold, initiate lifestyle modifications as first-line therapy for all patients, and start pharmacologic treatment with thiazide diuretics, ACE inhibitors/ARBs, or calcium channel blockers when BP remains ≥130/80 mm Hg, titrating to achieve target BP <130/80 mm Hg in adults under 65 years. 1, 2

Screening and Detection

• Screen all adults routinely for hypertension given that up to 33% of men aged 20-44 years with hypertension are unaware of their condition, and the asymptomatic nature of the disease allows silent progression to complications including stroke, heart failure, and chronic kidney disease. 1

• African American patients require particular attention as hypertension develops at younger ages and presents with higher rates of stroke and end-stage kidney disease at diagnosis compared to other ethnic groups. 1

Proper Blood Pressure Measurement Technique

• Measure BP in a relaxed, temperate environment using calibrated, validated automated devices with the patient seated and arm supported at heart level for at least one minute before the initial reading. 1

• Record pulse rate and rhythm before BP measurement, as automated devices are inaccurate with irregular rhythms requiring manual auscultation instead. 1

• If the first measurement is ≥140/90 mm Hg, take two additional readings at least one minute apart and record the lower of the last two readings as the patient's BP. 1

• For patients undergoing vascular or renal procedures, measure BP in both arms; if systolic difference exceeds 20 mm Hg, repeat and subsequently use the arm with higher readings. 1

Diagnosis of Hypertension

• Define hypertension as BP ≥130/80 mm Hg, which adds approximately 31 million Americans to those requiring treatment compared to the older 140/90 mm Hg threshold. 1, 2

• When office BP is between 140/90 and 179/109 mm Hg, offer ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to confirm the diagnosis before initiating treatment, as this reduces white coat hypertension misdiagnosis. 1

• Diagnose hypertension if ABPM/HBPM shows mean BP ≥150/95 mm Hg, or ≥135/85 mm Hg with evidence of target organ damage (left ventricular hypertrophy, chronic kidney disease, retinopathy, or previous cardiovascular events). 1

• If BP is ≥180/110 mm Hg in the office, consider this severe hypertension and evaluate for immediate treatment without waiting for confirmatory out-of-office measurements. 1

Risk Stratification and Target Organ Assessment

• Assess overall cardiovascular risk through history, physical examination, urinalysis, serum creatinine, glucose, lipid panel, and ECG to identify target organ damage. 3

• Hypertension causes 51% of all stroke deaths worldwide and 45% of heart disease deaths, with stroke risk doubling for each 20/10 mm Hg increment above 115/75 mm Hg. 4

• Identify patients with compelling indications (prior stroke, heart failure, post-MI, chronic kidney disease, diabetes) who require more aggressive BP control and specific drug therapies. 4

First-Line Treatment: Lifestyle Modifications

• Initiate lifestyle modifications for all patients with hypertension as these interventions are partially additive and enhance pharmacologic therapy effectiveness. 2

• Recommend weight loss for overweight/obese patients, as this provides substantial BP reduction. 2

• Advise dietary sodium restriction to <2.3 g/day and potassium supplementation through a healthy dietary pattern rich in fruits, vegetables, and low-fat dairy products. 2

• Prescribe regular physical activity (at least 150 minutes of moderate-intensity aerobic exercise weekly). 2

• Counsel moderation or elimination of alcohol consumption, as excessive intake elevates BP. 2

Pharmacologic Treatment Initiation

• Start antihypertensive medication when BP remains ≥130/80 mm Hg despite lifestyle modifications, or immediately in patients with BP ≥140/90 mm Hg and high atherosclerotic cardiovascular disease risk. 2

• First-line drug therapy consists of thiazide or thiazide-like diuretics (hydrochlorothiazide or chlorthalidone), ACE inhibitors or ARBs (enalapril or candesartan), or calcium channel blockers (amlodipine). 2

• These three drug classes have equivalent efficacy in reducing cardiovascular events and mortality, so selection should be based on patient-specific factors including comorbidities, contraindications, and tolerability. 2

Treatment Targets

• Target BP <130/80 mm Hg for adults under 65 years to achieve approximately 20-30% reduction in cardiovascular events with each 10 mm Hg systolic BP reduction. 2

• For adults ≥65 years, target systolic BP <130 mm Hg while monitoring for orthostatic hypotension and falls. 2

• Lower the target to <130/80 mm Hg for patients with diabetes or chronic kidney disease to prevent progression of target organ damage. 4

Medication Titration and Optimization

• Titrate medication dosages upward (except diuretics which have a ceiling effect) if BP remains above target after 2-4 weeks of therapy. 3

• If monotherapy at optimal dose fails to achieve target BP, add a second agent from a different class with complementary mechanism of action rather than switching medications. 3, 5

• Common effective combinations include: ACE inhibitor/ARB + calcium channel blocker, ACE inhibitor/ARB + thiazide diuretic, or calcium channel blocker + thiazide diuretic. 2

Resistant Hypertension Management

• Define resistant hypertension as BP remaining uncontrolled despite three antihypertensive agents at optimal doses, including a diuretic. 5

• Before diagnosing true resistant hypertension, exclude pseudoresistance (poor adherence, white coat effect, improper BP measurement technique), secondary causes, and interfering substances (NSAIDs, decongestants, excessive alcohol, licorice). 5

• Add a mineralocorticoid receptor antagonist (spironolactone) as the fourth agent for true resistant hypertension, as this is highly effective even without biochemical evidence of aldosterone excess. 5

• Screen for secondary causes of hypertension (primary aldosteronism, renal artery stenosis, obstructive sleep apnea, pheochromocytoma, Cushing's syndrome) when clinically indicated by young age at onset, severe or resistant hypertension, or suggestive clinical features. 5

Monitoring and Follow-Up

• Monitor BP every 3-6 months once target is achieved to ensure sustained control and assess medication adherence. 1

• Encourage home BP monitoring for all treated patients, as this improves adherence and provides more accurate assessment of BP control than office measurements alone. 6, 7

• Recognize that office BP measurements typically overestimate true BP by 10-15 mm Hg due to white coat effect, making home or ambulatory monitoring valuable for treatment decisions. 6

Critical Pitfalls to Avoid

• Never rely on a single elevated BP reading to diagnose hypertension or adjust therapy, as anxiety and stress in clinical settings cause falsely elevated measurements. 1, 6

• Do not delay treatment in high-risk patients (those with target organ damage or BP ≥160/100 mm Hg), as the asymptomatic nature of hypertension allows progressive cardiovascular damage. 1

• Avoid abruptly discontinuing beta-blockers in patients already taking them, as withdrawal causes rebound hypertension and silent myocardial ischemia. 8

• Do not start new beta-blocker therapy perioperatively in beta-blocker-naive patients, as this increases postoperative mortality from hypotension and stroke. 8

• Despite proven benefits of BP control, only 44% of US adults with hypertension achieve control to <140/90 mm Hg, highlighting the need for systematic approaches to screening, treatment intensification, and adherence support. 2