Hypertension - key point
How to manage hypertension
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If a patient presents with an elevated blood pressure of 120-129/<80
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the best approach is to recommend non-pharmacologic therapy and re-assess in 3-6 months.
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If a patient presents with stage 1 hypertension (130-139/80-89)
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1st consider whether the patient has clinical ASCVD (i.e., stroke, CAD, PAD) or has more than a 10% 10-year risk of heart disease or stroke using the ASCVD risk calculator.
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If the patient does not meet these criteria, there is no indication to start antihypertensive medication. Reassess the patient's blood pressure in 3-6 months.
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If the patient has clinical ASCVD or a 10-year risk of more than 10%, consider treatment.
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1st-line: thiazide diuretics, CCBs, ACE-inhibitors or ARBs.
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Beta-blockers are NOT first line (in most cases)
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If a patient presents with stage 2 hypertension BP >/= 140/90
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Recommendations include non-pharmacologic therapy and two drug combinations.
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Is it better to titrate to a maximum dose of 1 BP or use multiple BP medications at a lower dose?
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Multiple BP meds at a lower dose have been shown to effectively lower BP with fewer side effects.​​​
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Resistant Hypertension
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If the clinic blood pressure (BP) exceeds 130/80 and the patient takes a minimum of three blood pressure medications, including a diuretic at the maximum or maximum tolerated doses, it is advisable to assess the patient for resistant hypertension.
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Step 1 in management
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To ensure an accurate assessment, it is crucial to rule out pseudo-resistance by confirming medication adherence and conducting 24-hour ambulatory blood pressure (BP) monitoring or home BP monitoring to exclude the white coat effect.
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Ensure that the patient receives a three-drug regimen, including a RAS blocker (renin-angiotensin system blocker), a calcium channel blocker (CCB), and a diuretic at the maximum or maximally tolerated dose.
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Step 2 in management
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Please substitute the diuretic with chlorthalidone, as it has a longer half-life and can be administered to patients with chronic kidney disease (CKD), as demonstrated in the CLICK trial.
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Step 3 in management
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Add a mineralocorticoid-receptor antagonist, such as spironolactone or eplerenone.
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