Management of Hypertension in Primary Care
For most patients with newly diagnosed hypertension, initiate treatment with a two-drug combination from the following first-line classes: ACE inhibitors/ARBs, long-acting dihydropyridine calcium channel blockers, or thiazide-like diuretics, preferably as a single-pill combination. 1
Blood Pressure Thresholds for Treatment Initiation
- Start pharmacological treatment immediately for all patients with confirmed BP ≥140/90 mmHg, regardless of cardiovascular risk 1, 2
- For patients with BP 130-139/80-89 mmHg and existing cardiovascular disease, initiate treatment immediately 1
- For patients with BP 130-139/80-89 mmHg with diabetes or chronic kidney disease, initiate treatment 3, 2
- For patients with BP ≥160/100 mmHg, begin with two antihypertensive medications to achieve control more rapidly 3
Blood Pressure Targets
- Target <130/80 mmHg for most adults under 65 years with high cardiovascular risk, diabetes, or chronic kidney disease 1, 4
- For patients with diabetes, chronic kidney disease, or established cardiovascular disease: optimal target is <130/80 mmHg 3
- For non-diabetic patients without high-risk features: target <140/85 mmHg (audit standard <150/90 mmHg) 3
- For elderly patients ≥65 years: individualize based on tolerability, aiming for systolic 130-139 mmHg if well tolerated 2
Preferential Order of Antihypertensive Drug Classes
First-Line Agents (Equal Priority):
- ACE inhibitors (e.g., lisinopril 10-40 mg daily) 1, 2, 5
- Angiotensin receptor blockers (ARBs) (e.g., losartan 50-100 mg daily) 1, 2, 5
- Long-acting dihydropyridine calcium channel blockers (e.g., amlodipine 5-10 mg daily) 1, 2, 5
- Thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide) 1, 4, 5
Compelling Indications for Specific First-Line Classes:
- Heart failure or post-MI: ACE inhibitor or ARB as first choice 3, 2
- Chronic kidney disease with albuminuria: ACE inhibitor or ARB as first choice 3, 2
- Diabetic nephropathy (Type 1 or 2): ACE inhibitor or ARB as first choice 3
- Coronary artery disease: ACE inhibitor or ARB as first choice 3, 2
- Black patients: Calcium channel blocker or thiazide-like diuretic as first choice 2, 6
- Elderly patients or isolated systolic hypertension: Calcium channel blocker or thiazide-like diuretic 3, 1
Second-Line Agents:
- Beta-blockers - Only when compelling indication exists (post-MI, angina, heart failure with reduced ejection fraction) 3; NOT recommended as routine first-line 2
Third-Line/Resistant Hypertension:
- Mineralocorticoid receptor antagonists (spironolactone 25-50 mg daily) - Add as fourth agent for resistant hypertension 3, 1, 2
Treatment Algorithm
Step 1: Initial Therapy
- For BP 140-159/90-99 mmHg in low-risk patients: start with single agent from first-line classes 2
- For BP ≥160/100 mmHg or high-risk patients: start with two-drug combination (preferably single-pill) 3, 1
- Preferred initial combinations: ACE inhibitor or ARB + calcium channel blocker, OR ACE inhibitor or ARB + thiazide-like diuretic 1
Step 2: Escalation at 4 Weeks if Target Not Achieved
- Increase to triple therapy: RAS blocker (ACE inhibitor or ARB) + calcium channel blocker + thiazide-like diuretic, preferably as single-pill combination 1, 2
Step 3: Resistant Hypertension (Not Controlled on 3 Drugs)
- Add spironolactone 25-50 mg once daily as fourth agent 3, 1, 2
- Before diagnosing resistant hypertension, exclude: medication non-adherence, white coat hypertension, secondary causes, and BP-raising substances (NSAIDs, steroids, oral contraceptives) 3
Critical Contraindications and Cautions
Absolute Contraindications:
- ACE inhibitors/ARBs: Pregnancy, bilateral renal artery stenosis 3
- Beta-blockers: Asthma, severe COPD, high-degree heart block 3
- Combination of ACE inhibitor + ARB: Avoid due to increased adverse effects without benefit 3, 2
Important Cautions:
- ACE inhibitors/ARBs in chronic kidney disease: Monitor creatinine and potassium 7-14 days after initiation 4; can continue until eGFR <30 mL/min/1.73 m² 3
- Beta-blockers as monotherapy: Avoid in heart failure unless patient has reduced ejection fraction, prior MI, or active angina 3
- Dihydropyridine calcium channel blockers: Avoid in heart failure with reduced ejection fraction unless required for angina or refractory hypertension 1
Essential Baseline Evaluation
Before initiating treatment, obtain: 3, 4
- Fasting glucose or HbA1c
- Serum creatinine with eGFR
- Lipid panel
- Urinalysis for proteinuria
- Electrocardiogram
- Serum potassium
Do not delay treatment while awaiting test results if BP ≥160/100 mmHg 2, 4
Lifestyle Modifications (Initiate Simultaneously with Pharmacotherapy)
- Sodium restriction: <2,300 mg/day (ideally <1,500 mg/day) 4, 5
- DASH diet: 8-10 servings/day fruits/vegetables, 2-3 servings/day low-fat dairy 4
- Physical activity: ≥150 minutes/week moderate-intensity aerobic exercise 4
- Weight loss: If BMI ≥25 kg/m² 4, 5
- Alcohol limitation: Moderate or eliminate consumption 5
- Smoking cessation 1
Follow-Up and Monitoring
- Recheck BP in 1 month after initiating or changing therapy 2, 4
- Monthly follow-up until target BP achieved 1, 2
- Once controlled: every 3-6 months 3, 1
- Annual proteinuria screening 3
- For patients on ACE inhibitors, ARBs, or diuretics: check creatinine and potassium 7-14 days after initiation 4
Common Pitfalls to Avoid
- Do not delay pharmacotherapy for a 3-6 month trial of lifestyle modification alone if BP ≥140/90 mmHg 4
- Do not use beta-blockers as first-line unless compelling indication exists 2
- Do not combine ACE inhibitor with ARB 3, 2
- Do not use hydrochlorothiazide when chlorthalidone is available (superior cardiovascular outcomes) 4
- Do not underdose: Most patients require at least two drugs to achieve target 3, 1
- Do not ignore secondary causes in patients with resistant hypertension, onset <30 years, or abrupt loss of control 3