What is the algorithm for treating arterial hypertension?

From the Guidelines

The treatment algorithm for arterial hypertension should begin with lifestyle modifications and, if necessary, pharmacotherapy with a single agent, preferably a blocker of the renin-angiotensin system, a thiazide diuretic, or a calcium antagonist, with a goal to achieve a blood pressure of <130/80 mmHg, as recommended by the most recent guidelines 1. The algorithm for treating arterial hypertension involves several steps, including:

• Lifestyle modifications, such as weight reduction, adopting the DASH diet, reducing sodium intake, increasing physical activity, and moderating alcohol consumption.
• If blood pressure remains elevated, pharmacotherapy is initiated with a single agent at a low dose, with dose adjustments every 2-4 weeks based on response.
• First-line medications include thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs.
• If blood pressure control is not achieved with a single medication at maximum dose, a second agent from a different class is added.
• For stage 2 hypertension (≥160/100 mmHg), treatment often begins with two medications from different classes.
• In resistant hypertension, a third agent is added, typically including a thiazide diuretic if not already prescribed. Some key considerations when treating arterial hypertension include:
• Special considerations apply for patients with comorbidities, such as diabetes or chronic kidney disease, where ACE inhibitors or ARBs are preferred.
• Beta-blockers are beneficial for patients with coronary artery disease.
• The goal of treatment should be individualized, taking into account the patient's age, comorbidities, and tolerance to treatment.
• The use of single-pill combinations can improve medication adherence and achieve better blood pressure control with fewer adverse effects 1. It's worth noting that different guidelines, such as the ESC/ESH and ACC/AHA guidelines, may have slightly different recommendations for the treatment of arterial hypertension, but the overall approach remains similar 1.

From the FDA Drug Label

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 algorithm of treatment for arterial hypertension typically involves a stepwise approach:

• Initial treatment: Start with a single medication, such as lisinopril or losartan, and adjust the dose as needed to achieve blood pressure goals.
• Combination therapy: If blood pressure goals are not met with a single medication, consider adding another medication from a different class.
• Lifestyle modifications: Encourage patients to make lifestyle changes, such as dietary modifications, increased physical activity, and smoking cessation, to help lower blood pressure.
• Regular monitoring: Regularly monitor blood pressure and adjust treatment as needed to achieve and maintain blood pressure goals.

It is essential to consider individual patient factors, such as comorbidities and concomitant medications, when selecting and adjusting treatment. 2 3 2

From the Research

Algorithm of Treatment for Arterial Hypertension

The treatment of arterial hypertension involves a combination of lifestyle modifications and pharmacologic therapy.

• Lifestyle modifications include weight loss, a healthy dietary pattern with low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption 4.
• The decision to initiate antihypertensive medication should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 4.
• First-line drug therapy for hypertension consists of a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker 4, 5.

Blood Pressure Targets

• The target blood pressure for most people is less than 130/80 mm Hg for adults under 65 years and less than 130 mm Hg for adults 65 years and older 4.
• For patients with chronic kidney disease and diabetes mellitus, a blood pressure goal of less than 140/90 mm Hg is recommended 5.
• However, some studies suggest that individualized blood pressure targets should be based on comorbidities, hypertension-mediated organ damage, and individual tolerability 6.

Choice of Antihypertensive Medication

• Thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers are preferred medications for nonblack patients 5.
• For black patients, thiazide diuretics and calcium channel blockers are preferred 5.
• However, some studies suggest that angiotensin receptor blockers may be a better choice than angiotensin-converting enzyme inhibitors due to fewer adverse events 7.

Monitoring and Adjusting Treatment

• Accurate blood pressure measurement with validated devices is crucial for the diagnosis and monitoring of hypertension 6.
• Out-of-office blood pressure measurements are also important for assessing blood pressure control 6.
• Simplified antihypertensive drug treatment, such as single-pill combinations, can enhance adherence to medication and speed up the process of achieving blood pressure targets 6.