Approach to a Patient with Hypertension

Diagnosis and Initial Assessment

The European Society of Cardiology recommends confirming the diagnosis of hypertension as soon as possible (within 1 month) using out-of-office blood pressure monitoring (home or ambulatory BP), excluding hypertensive emergency, and initiating prompt pharmacological treatment with two antihypertensive medications from different classes alongside lifestyle modifications 1, 2
Immediately assess for signs and symptoms of acute target organ damage, including severe headache, visual changes, chest pain, dyspnea, neurological deficits, or altered mental status, in patients with blood pressure ≥180/110 mmHg or any signs of target organ damage 1, 2
For blood pressure 160-179/100-109 mmHg without acute organ damage, this is a hypertensive urgency requiring confirmation and treatment initiation within 1 month 1, 2

The European Heart Journal recommends initiating treatment with two antihypertensive medications from different classes immediately for patients with blood pressure 160/110 mmHg, rather than monotherapy, as most patients at this level require multiple agents to achieve control 4
For non-Black patients, the first choice is an ACE inhibitor or ARB + thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) 5, 7
For Black patients, the first choice is a dihydropyridine calcium channel blocker + thiazide-like diuretic 5, 7
Patients with diabetes and albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g) should include an ACE inhibitor or ARB in the regimen for renal protection 4, 3

The European Heart Journal recommends targeting blood pressure <140/90 mmHg as a minimum, with an optimal goal of <130/80 mmHg for most adults 3, 5, 6
For adults <65 years, aim for systolic blood pressure 120-129 mmHg if well tolerated 5
For older adults ≥65 years, target systolic blood pressure 130-139 mmHg 3
Achieve target blood pressure within 3 months of treatment initiation 5, 7, 6

Implement evidence-based lifestyle interventions immediately alongside pharmacotherapy, including dietary modifications, weight management, physical activity, alcohol restriction, and smoking cessation 1, 2, 5
Restrict sodium intake to approximately 2 g/day (equivalent to 5 g of salt/day) 2, 5
Adopt a Mediterranean or DASH diet pattern high in vegetables, fresh fruits, fish, nuts, unsaturated fatty acids (olive oil), and low-fat dairy products with low consumption of red meat 1, 2

Reassess blood pressure within 1 month after initiating therapy to evaluate response and adjust medications 5, 7, 6
Consider home blood pressure monitoring or repeat ambulatory blood pressure monitoring to confirm office readings and detect white-coat or masked hypertension 5, 7
Monitor serum creatinine, eGFR, and potassium levels at least annually, or more frequently if on ACE inhibitor, ARB, or diuretic 2, 4