What is the management of hypertension (high blood pressure) in primary care?

From the Guidelines

Management of high blood pressure in primary care should prioritize a systematic approach combining lifestyle modifications and medication therapy, with a focus on achieving blood pressure targets of <130/80 mmHg for most adults, as recommended by the most recent guidelines 1. The initial treatment should focus on lifestyle changes, including:

• Weight reduction
• Adopting the DASH diet (rich in fruits, vegetables, and low-fat dairy)
• Reducing sodium intake to less than 2.3g daily
• Regular physical activity (150 minutes weekly)
• Limiting alcohol consumption For pharmacological management, first-line medications include:
• Thiazide diuretics (hydrochlorothiazide 12.5-25mg daily)
• ACE inhibitors (lisinopril 10-40mg daily)
• ARBs (losartan 50-100mg daily)
• Calcium channel blockers (amlodipine 5-10mg daily) Treatment should begin with a single agent at a low dose, with follow-up in 2-4 weeks to assess efficacy and side effects. For patients with stage 2 hypertension (BP ≥140/90 mmHg), consider initiating two medications from different classes, as recommended by the American Heart Association 1. Regular monitoring is essential, with home blood pressure measurements providing valuable data between office visits. Medication adherence should be assessed at each visit, as non-adherence is a common cause of treatment failure, and patients should be educated on the importance of medication adherence 1. Hypertension control is crucial as it significantly reduces the risk of stroke, heart attack, heart failure, and kidney disease, which are the major complications of sustained high blood pressure. The primary goal of treatment is to achieve the maximum reduction in the long-term total risk of cardiovascular morbidity and mortality, and blood pressure should be intensively lowered to at least <140/90 mmHg and to definitely lower values, if tolerated, in all hypertensive patients, and <130/80 mmHg in patients with diabetes 1.

From the FDA Drug Label

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 one 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 management of high blood pressure in primary care involves comprehensive cardiovascular risk management. This includes:

• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake It is also noted that many patients will require more than one drug to achieve blood pressure goals, and that specific advice on goals and management can be found in published guidelines, such as those of the National High Blood Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 2 3.

From the Research

Management of High Blood Pressure in Primary Care

• High blood pressure is a common condition encountered in primary care, and nonpharmacologic strategies have been shown to help lower blood pressure 4.
• Lifestyle modifications, such as a diet emphasizing vegetables, fruits, and whole grains, limiting sodium intake, and exercising regularly, are recommended for all patients with hypertension 4, 5.
• Other nonpharmacologic strategies include weight loss, tobacco cessation, decreased alcohol consumption, biofeedback, and self-measured blood pressure monitoring 4.
• For patients with obstructive sleep apnea, the use of continuous positive airway pressure has been shown to improve blood pressure 4.

Pharmacologic Management

• Antihypertensive drug combinations, such as lisinopril, losartan, or valsartan alone or in combination with hydrochlorothiazide, have been shown to be effective in reducing blood pressure and improving arterial stiffness 6.
• The combination of amlodipine and lisinopril has been shown to have a significant additional blood pressure-lowering effect compared to monotherapy 7.
• The combination of amlodipine plus valsartan has been compared to lisinopril plus hydrochlorothiazide in patients with stage 2 hypertension, and both regimens were found to be well tolerated and efficacious 8.

Key Findings

• Nonpharmacologic strategies, such as lifestyle modifications, can help lower blood pressure and should be recommended for all patients with hypertension 4, 5.
• Antihypertensive drug combinations can be effective in reducing blood pressure and improving arterial stiffness, and the choice of combination should be individualized based on patient characteristics and response to treatment 6, 7, 8.