Initial Treatment of Hypertension

Published - Written by Carla Rothaus

What drug classes are recommended for the initial management of hypertension?

Although in recent years hypertension has been defined as a blood pressure of 140/90 mm Hg or more, the 2017 American College of Cardiology–American Heart Association (ACC–AHA) Hypertension Guideline adopted a lower threshold, in which hypertension is defined as a systolic blood pressure of 130 mm Hg or more or a diastolic blood pressure of 80 mm Hg or more. Read the latest NEJM Clinical Practice Article here.

Table 1. (10.1056/NEJMcp1613481/T1) Classification of Blood Pressure in Adults.

Clinical Pearls

Q: When are lifestyle modifications alone a reasonable approach to the initial management of hypertension?

A: Treatment decisions depend on whether there is preexisting cardiovascular disease, diabetes mellitus, or chronic kidney disease. For patients with stage 1 hypertension and without these conditions, the 2017 ACC–AHA guideline recommends calculation of the estimated 10-year risk of cardiovascular disease (http://tools.acc.org/ASCVD-Risk-Estimator/). If this risk is less than 10%, it is reasonable to implement lifestyle modifications alone for a period of 3 to 6 months. For those with stage 2 hypertension or with preexisting cardiovascular disease, diabetes mellitus, chronic kidney disease, or a 10-year risk of cardiovascular disease of 10% or higher, both lifestyle change and medication are recommended.

Q: What are some nonpharmacologic approaches to managing hypertension?

A: Recommended strategies include restriction of dietary sodium intake below 1500 mg per day, weight loss if the patient is overweight or obese, aerobic or resistance exercise for 90 to 150 minutes per week, moderation of alcohol intake (≤2 drinks daily for men and ≤1 drink for women), and enhanced intake of potassium-rich foods. Each of these strategies is likely to reduce systolic pressure by 3 to 8 mm Hg and diastolic pressure by 1 to 4 mm Hg. Patients should be encouraged to minimize the use of nonsteroidal antiinflammatory drugs, decongestants, and amphetamines (as used for attention deficit–hyperactivity disorder).


Morning Report Questions

Q: What drug classes are recommended for the initial management of hypertension?

A: Multiple clinical trials have shown that blood pressure can be effectively reduced by medications and that doing so results in a reduced incidence of target-organ events. The initial agent can be selected from one of four drug classes: angiotensin-converting–enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), calcium-channel blockers, and thiazide-type diuretics; each class has been shown to reduce cardiovascular events. The patient’s lifestyle, coexisting conditions, and clinical characteristics should be considered in selecting an agent. For example, patients with a high salt intake (e.g., eating primarily processed foods) may have a greater blood-pressure reduction with diuretic therapy, whereas those restricting salt intake may have a greater response to blockade of the renin–angiotensin system.

Q: What are some of the side effects associated with the recommended pharmacologic therapies for hypertension?

A: Caution is advised with thiazide use in patients 65 years of age or older, particularly in women and in patients of either sex who have hyponatremia or a low normal sodium level at baseline; in such patients, the serum level of sodium should be checked within 1 to 2 weeks after a thiazide diuretic has been started or the dose has been increased. ACE inhibitors are effective and have an acceptable side-effect profile in most patients, although cough develops in up to 20% of patients. Angioedema is an infrequent complication overall but is two to four times as common among blacks as among whites (estimated incidence, 3.9 cases per 1000 person-years among blacks and 0.8 cases among whites). Calcium-channel blockers are associated with additional side effects, primarily edema for the dihydropyridine agents (nifedipine, amlodipine, and others) and constipation for the nondihydropyridines (verapamil and diltiazem).

Table 2. (10.1056/NEJMcp1613481/T2) Initial Choices for Antihypertensive Agents and Usual Doses.

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