Initial Evaluation and Management of Stage 1 Hypertension

Initial Laboratory Evaluation

• The American College of Cardiology recommends routine laboratory tests for all hypertensive patients, including urine strip test for blood and protein, blood electrolytes and creatinine, blood glucose, serum total:HDL cholesterol ratio, and 12-lead electrocardiograph 1, 2, 3

Risk Assessment and Treatment Decision

• The American Heart Association suggests calculating 10-year cardiovascular disease (CVD) risk using appropriate risk calculators, assessing for target organ damage, and evaluating for comorbidities that may influence treatment decisions 2, 3, 4
• The European Society of Cardiology recommends assessing for target organ damage (heart, kidneys, eyes, brain) in patients with stage 1 hypertension 1, 2

Treatment Approach Based on Risk

• For patients with stage 1 hypertension and 10-year CVD risk <10% and no target organ damage or diabetes, the American College of Cardiology recommends beginning with non-pharmacological therapy, including lifestyle modifications such as sodium restriction, increased dietary potassium, weight loss, physical activity, and alcohol moderation 2, 3, 5
• For patients with stage 1 hypertension and 10-year CVD risk ≥10% OR target organ damage OR diabetes present, the American Heart Association recommends initiating both non-pharmacological and pharmacological therapy 2, 3

Non-Pharmacological Interventions

• The American College of Cardiology recommends lifestyle modification advice, including sodium restriction (<1500 mg/day), increased dietary potassium (3500-5000 mg/day), weight loss if overweight/obese, physical activity (90-150 minutes/week of aerobic exercise), and alcohol moderation (≤2 drinks/day for men, ≤1 for women) 5, 4

Pharmacological Therapy

• The American College of Cardiology recommends first-line options for pharmacological therapy, including thiazide or thiazide-like diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers 3, 5
• For patients with diabetes or chronic kidney disease, the American Diabetes Association recommends ACE inhibitors or ARBs as preferred initial agents 5, 4

Treatment Targets

• The American College of Cardiology recommends target BP <140/85 mmHg for most patients, and target BP <130/80 mmHg for patients with diabetes, renal impairment, or established cardiovascular disease 1, 4

Follow-up Plan

• The American Heart Association recommends reassessing patients on non-pharmacological therapy only in 3-6 months, and following up with patients starting pharmacological therapy in 1 month 2, 3
• The European Society of Cardiology suggests monitoring for medication adherence, side effects, and BP response, and assessing electrolytes and renal function 2-4 weeks after initiating ACE inhibitors, ARBs, or diuretics 2, 3

Indications for Specialist Referral

• The American College of Cardiology recommends considering referral for suspected secondary hypertension, resistant hypertension, accelerated hypertension or hypertensive emergency, and unusual BP variability or suspected white coat hypertension 1, 2