Initial Management of Hypertension
Diagnosis Confirmation
- Confirm hypertension diagnosis with repeated office BP measurements ≥140/90 mmHg, ideally validated by home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 1, 3
- Use validated automated upper arm cuff device with appropriate cuff size 1
- Measure BP in both arms at first visit; if consistent difference exists, use the arm with higher BP for future measurements 3
Initial Pharmacological Approach
- For Black patients, first-line therapy should include a low-dose ARB plus either a dihydropyridine calcium channel blocker (DHP-CCB) or a thiazide-like diuretic 1, 2
- CCBs and thiazide diuretics are more effective in lowering blood pressure in African Americans than RAS inhibitors or beta blockers 2
- Amlodipine is as effective as chlorthalidone and more effective than lisinopril in reducing BP, cardiovascular disease, and stroke events in African Americans 2
Treatment Algorithm Based on BP Level
- If BP remains uncontrolled after initial therapy, increase to full dose 1
- Add third agent (diuretic or ARB/ACEI if not already included) 1, 2
Special Considerations
- For those with chronic kidney disease and proteinuria, include an ACE inhibitor or ARB in the regimen 2
- African Americans have greater risk of angioedema with ACE inhibitors, making ARBs often preferable 2
Monitoring and Follow-up
- Target BP: <130/80 mmHg 3, 2
- Monitor BP control and aim to achieve target within 3 months 3
- If BP remains uncontrolled despite optimized triple therapy, refer to a specialist with hypertension expertise 3