Hypertension Management

Introduction

Hypertension management involves a combination of lifestyle modifications, diagnostic evaluation, and pharmacological interventions to achieve optimal blood pressure control, as recommended by the European Society of Cardiology and the American Heart Association 1, 2

The European Society of Cardiology recommends a blood pressure target of 120-129/80 mmHg for most patients, with a less stringent target (<140/90 mmHg) for very old patients (≥85 years) or those with symptomatic orthostatic hypotension 1
For older patients (≥65 years), a systolic blood pressure target of 130-139 mmHg is recommended, as suggested by the European Society of Cardiology 1
The American College of Cardiology recommends a target BP of <130/80 mmHg for most patients with heart failure, with gradual titration of medications to target doses 2, 1, 3

Regular physical activity, including at least 30 minutes of moderate aerobic exercise, 5-7 days a week, is recommended by the European Society of Cardiology to help manage hypertension 1
A diet rich in fruits, vegetables, fish, nuts, and unsaturated fatty acids, with a reduced sodium intake (<100 mmol/day), is recommended to help lower blood pressure 1
Maintaining a healthy weight, with a body mass index (BMI) between 20-25 kg/m², and a waist circumference of less than 94 cm for men and less than 80 cm for women, is recommended to reduce the risk of hypertension 1
Limiting alcohol intake to less than 14 units per week for men and less than 8 units per week for women is recommended by the European Society of Cardiology to help manage hypertension 1

The American Heart Association recommends screening for secondary hypertension, including primary hyperaldosteronism, pheochromocytoma, and sleep apnea, to identify underlying causes of hypertension 4
The American College of Cardiology recommends a first-line antihypertensive regimen including an ACE inhibitor or ARB, a beta-blocker, and a diuretic, with an aldosterone antagonist in appropriate patients, to achieve optimal blood pressure control 2

The American College of Cardiology and the European Heart Society recommend using ACE inhibitors or ARBs as first-line therapy, with a target blood pressure of <130/80 mmHg, and adding a diuretic or a calcium channel blocker as needed to achieve optimal blood pressure control 2, 1, 3
Angiotensin receptor blockers (ARBs) are preferred due to their favorable hepatic safety profile and efficacy in blood pressure control, as recommended by the European Heart Society and the American College of Cardiology 5, 1, 6
The European Heart Society recommends adding spironolactone or eplerenone for patients with NYHA class II-IV symptoms, with close monitoring of potassium and renal function, to help manage hypertension and heart failure 1, 3
The American College of Cardiology recommends using antihypertensive medications with minimal hepatic metabolism, such as dihydropyridine calcium channel blockers, which can be added to ARB or ACE inhibitor monotherapy if blood pressure remains uncontrolled, with caution for potential drug interactions with antiretroviral therapy in patients with HIV 7

Medication	Recommended Use
ARBs	First-line therapy, especially in patients with liver disease
ACE inhibitors	First-line therapy, with a target blood pressure of <130/80 mmHg
Dihydropyridine CCBs	Add-on therapy with ARBs or ACE inhibitors, or as alternative monotherapy
Thiazide diuretics	Add-on therapy for volume control, or as alternative monotherapy
Long-acting dihydropyridine CCBs	Effective in reducing blood pressure and preventing cardiovascular events
Beta blockers	Not recommended as first-line therapy, unless specific indications (e.g., angina, post-MI, heart failure)

Single-pill combinations significantly improve medication adherence compared to separate pills, and medication timing: Take medications at the most convenient time of day to establish a habitual pattern and improve adherence, as recommended by the European Society of Cardiology and the American College of Cardiology 1, 8
Caregivers of patients on single pill triple therapy (ACEi, CCB, and diuretic) for hypertension should be educated about medication adherence, monitoring for side effects, blood pressure tracking, and when to seek medical attention, as recommended by the American College of Cardiology 7

Black patients may benefit from CCBs and thiazide diuretics as monotherapy, and for Black patients, the medication combination may include an ARB rather than an ACEi as first-line therapy, as recommended by the American College of Cardiology and the American Heart Association 3, 7
Pregnant patients require different medication choices (methyldopa, labetalol, nifedipine), as recommended by the European Society of Cardiology 1
Patients ≥85 years, with symptomatic orthostatic hypotension, or with moderate-to-severe frailty should consider starting with monotherapy, as recommended by the European Society of Cardiology 1

Blood pressure should be monitored monthly after medication adjustments until target is reached, with consideration for further lowering to 120/80 mmHg in appropriate patients, as recommended by the American College of Cardiology and the European Heart Society 5, 9, 10
Patients should be followed up monthly after initiation of therapy until target blood pressure is reached, then every 3-6 months, as recommended by the American College of Cardiology and the European Heart Society 9, 11, 8
Baseline LFTs should be checked before initiating therapy, and LFTs should be monitored at 1-3 months after starting treatment and then every 6 months, as recommended by the American College of Cardiology and the European Heart Society 5, 9, 11