Hypertension Management

Patient Assessment and Treatment

The International Society of Hypertension recommends outpatient management for asymptomatic patients with severe hypertension who don't have evidence of acute end-organ damage 1
Hypertension management involves a combination of lifestyle modifications and pharmacological interventions to achieve optimal blood pressure control, as recommended by the American Heart Association and the European Society of Cardiology 2, 3
The recommended blood pressure targets are:
Patient Population Blood Pressure Target
Most patients < 130/80 mmHg
Diabetic patients < 130/80 mmHg
Patients 65-79 years 130-139/80 mmHg
Patients ≥80 years 140-150/<80 mmHg
First-line medications for hypertension management include:
Losartan (ARB) monotherapy is recommended as the initial treatment, with the first combination being the addition of a thiazide or thiazide-like diuretic (preferably chlorthalidone), which is the most effective combination based on evidence 12, 13
The American Heart Association recommends thiazide-like diuretics, such as chlorthalidone (12.5-25 mg daily) or indapamide (1.25-2.5 mg daily), as first-line agents for blood pressure control due to their effectiveness and different side effect profiles 2
Special considerations for specific populations:

The American Heart Association recommends sodium restriction (<2400 mg/day), regular physical activity, DASH diet, weight management, and alcohol moderation as lifestyle modifications to manage hypertension 2
The European Society of Cardiology recommends achieving and maintaining a healthy body mass index, following a DASH diet, and regular exercise within patient's limitations, as well as alcohol moderation with ≤2 drinks/day for men and ≤1 drink/day for women 3, 17, 18, 19

The recommended lifestyle modifications are:

Lifestyle Modification	Recommendation
Body Mass Index	Achieve and maintain a healthy body mass index
Diet	Follow a DASH diet high in fruits, vegetables, and low-fat dairy, and low in red meat and fats
Exercise	Regular exercise within patient's limitations
Alcohol	Moderation with ≤2 drinks/day for men and ≤1 drink/day for women
Sodium	Restrict to 2.3 g/day or less

Monitor standing blood pressure to assess for postural hypotension, and always measure BP in both sitting and standing positions to detect orthostatic hypotension 9
Refer to specialist with hypertension expertise if blood pressure remains uncontrolled 1
Check blood pressure control within 3 months of medication changes, with a target blood pressure of <130/80 mmHg for most patients, and <130/80 mmHg for diabetic patients 1, 8
Monitor for electrolyte disturbances, metabolic effects, and renal function in patients on ACE inhibitors, ARBs, or diuretics, as recommended by the American Diabetes Association and the American Heart Association 10, 20, 21

Resistant hypertension is defined as BP ≥140/90 mmHg despite therapy with three antihypertensive drugs including a diuretic, as defined by the American Diabetes Association 22, 23
The American Diabetes Association recommends considering adding a mineralocorticoid receptor antagonist (such as spironolactone) as fourth-line therapy for resistant hypertension 7
Triple therapy with losartan + diuretic + calcium channel blocker is recommended for resistant hypertension, as recommended by the European Society of Cardiology 3
Bedtime dosing of at least one antihypertensive medication may improve BP control, as recommended by the American Diabetes Association 10
Consider withdrawing antihypertensive medications in patients over 80 years old with blood pressure below 140/90 mmHg, especially if the patient presents with frailty or medication-related adverse effects, as recommended by the American Geriatrics Society 1