What is the step-by-step treatment for a Caucasian person with Hypertension (High Blood Pressure)?

From the Guidelines

The treatment of hypertension in a white person should follow a stepwise approach, starting with lifestyle modifications and then initiating medication with a low dose ACEI/ARB, followed by a DHP-CCB, and then increasing to full dose, adding a thiazide-like diuretic, and finally adding spironolactone or other agents as needed, as recommended by the 2020 International Society of Hypertension global hypertension practice guidelines 1.

Step-by-Step Approach

The treatment approach involves:

• Lifestyle modifications, including sodium restriction, regular physical activity, weight loss, limited alcohol consumption, and adoption of the DASH diet
• Medication therapy, starting with:
  1. Low dose ACEI/ARB
  2. DHP-CCB
  3. Increase to full dose
  4. Add thiazide-like diuretic
  5. Add spironolactone or other agents as needed

Rationale

This approach is based on the latest guidelines and evidence, which suggest that ACEI/ARB and DHP-CCB are effective in reducing blood pressure and preventing cardiovascular events in white patients 1. The addition of a thiazide-like diuretic and spironolactone or other agents as needed can help achieve optimal blood pressure control.

Monitoring and Follow-up

Regular monitoring of blood pressure, electrolytes, and kidney function is essential, with follow-up visits every 2-4 weeks until blood pressure is controlled, then every 3-6 months thereafter 1.

From the FDA Drug Label

Analysis of age, gender, and race subgroups of patients showed that men and women, and patients over and under 65, had generally similar responses. Losartan was effective in reducing blood pressure regardless of race, although the effect was somewhat less in Black patients Lisinopril demonstrated superior reductions of systolic and diastolic compared to hydrochlorothiazide in a population that was 75% Caucasian Lisinopril was approximately equivalent to atenolol and metoprolol in reducing diastolic blood pressure, and had somewhat greater effects on systolic blood pressure. Lisinopril had similar blood pressure reductions and adverse effects in younger and older (> 65 years) patients. It was less effective in reducing blood pressure in Blacks than in Caucasians

The treatment of a white person with hypertension can be done with losartan or lisinopril.

• The initial dose of losartan is 50 mg once daily, and the dose can be increased to 100 mg once daily if necessary.
• The initial dose of lisinopril is 10 mg once daily, and the dose can be increased to 20 mg to 80 mg daily if necessary. The choice of medication and dosage should be based on the individual patient's needs and medical history, and should be determined by a healthcare professional 2, 3.

From the Research

Treatment of Hypertension in White People

• The treatment of hypertension in white people typically involves a combination of lifestyle modifications and pharmacologic therapy 4, 5, 6, 7, 8.
• Lifestyle modifications include:
  • Weight loss
  • Healthy dietary pattern with low sodium and high potassium intake
  • Physical activity
  • Moderation or elimination of alcohol consumption
• These lifestyle modifications have been shown to have a positive impact on blood pressure control, with studies demonstrating a reduction in systolic and diastolic blood pressure after intervention 5, 7, 8.

Pharmacologic Therapy

• First-line drug therapy for hypertension consists of:
  • Thiazide or thiazide-like diuretics (e.g. hydrochlorothiazide or chlorthalidone)
  • Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (e.g. enalapril or candesartan)
  • Calcium channel blockers (e.g. amlodipine)
• These medications should be titrated according to office and home blood pressure levels to achieve a target blood pressure of <130/80 mm Hg for adults <65 years and <130 mm Hg for adults ≥65 years 4, 6.

Benefits of Treatment

• Randomized clinical trials have established the efficacy of blood pressure lowering to reduce the risk of cardiovascular disease morbidity and mortality 4, 7.
• An reduction of 10 mm Hg in systolic blood pressure has been shown to decrease the risk of cardiovascular disease events by approximately 20-30% 4.
• Despite the benefits of blood pressure control, only 44% of US adults with hypertension have their blood pressure controlled to less than 140/90 mm Hg 4.