Treatment of High Blood Pressure (Hypertension)

BP Classification & Treatment Thresholds (ACC/AHA 2017)

Category	Systolic	Diastolic	Action
Normal	<120	<80	No intervention
Elevated	120-129	<80	Lifestyle modification only
Stage 1 HTN	130-139	80-89	Lifestyle ± drug therapy (based on CVD risk)
Stage 2 HTN	≥140	≥90	Lifestyle + drug therapy
Target (treated)	<130	<80	-

The ACC/AHA 2017 guidelines define hypertension at ≥130/80 mm Hg
European (ESC/ESH 2018) and NICE 2019 guidelines define it at ≥140/90 mm Hg - so thresholds differ depending on which guideline is followed

Step 1 - Lifestyle Modifications

These can lower systolic BP by 7-15 mm Hg and should be tried first in Stage 1 low-risk patients, and continued alongside medications in everyone:

Diet: Mediterranean or DASH diet - high in fruits, vegetables, whole grains, low-fat dairy, fish; low in refined carbs and saturated fats
Sodium: Reduce to <1,500 mg/day (most sodium comes from processed foods, not added salt)
Exercise: 90-150 min/week of moderate aerobic or dynamic resistance training (lowers BP by ~4-8 mm Hg)
Alcohol: ≤2 drinks/day for men, ≤1 drink/day for women
Weight loss, smoking cessation, stress management also contribute

Step 2 - Drug Therapy: The Four Core Classes

Current US and European guidelines converge on four preferred drug classes:

Class	Examples	Mechanism	Key Notes
ACE Inhibitors	Lisinopril, Ramipril	Block angiotensin I → II conversion	First-line; avoid in pregnancy, bilateral RAS, hyperkalemia; causes dry cough
ARBs (Angiotensin Receptor Blockers)	Losartan, Valsartan	Block angiotensin II at AT1 receptor	Same profile as ACEi, no cough; avoid in pregnancy
CCBs (Calcium Channel Blockers)	Amlodipine (DHP), Diltiazem/Verapamil (non-DHP)	Vasodilation, reduce cardiac contractility	Non-DHPs: avoid in AV block, severe LV dysfunction
Thiazide/Thiazide-like Diuretics	Hydrochlorothiazide, Chlorthalidone (preferred in US)	Reduce sodium absorption	Avoid in gout; caution in metabolic syndrome, hypokalemia

Beta-blockers are no longer first-line unless there is a specific compelling indication (angina, heart failure with reduced EF, atrial fibrillation for rate control, post-MI).

Step 3 - How to Start and Escalate

European Core Drug Treatment Algorithm for Uncomplicated Hypertension

From: Comprehensive Clinical Nephrology, 7th Ed.

Step 1 (Initial - Dual Combination): ACEi or ARB + CCB or Diuretic

Monotherapy considered only in low-risk Grade 1 HTN (SBP <150) or frail elderly (≥80 years)

Step 2 (Triple Combination): ACEi or ARB + CCB + Diuretic

Step 3 (Resistant HTN): Add spironolactone 25-50 mg once daily, or an alpha-blocker or beta-blocker; refer to specialist

Most patients require ≥2 drugs to achieve target. Single-pill combinations are strongly preferred to reduce pill burden and improve adherence - roughly 50% of patients stop antihypertensives within 1 year, and 20% never fill the first prescription.

Compelling Indications - Choose Specific Drug Classes

Comorbidity	Preferred Agents
Heart failure (reduced EF)	ACEi/ARB + beta-blocker + aldosterone antagonist
Post-MI / CAD	Beta-blocker + ACEi/ARB
Chronic kidney disease	ACEi or ARB (slow progression, reduce proteinuria)
Diabetes	ACEi or ARB (renal protection)
Stroke / cerebrovascular disease	ACEi + thiazide diuretic
Atrial fibrillation	Beta-blocker or non-DHP CCB (rate control)
Pregnancy	Labetalol, nifedipine, methyldopa; avoid ACEi/ARBs

Contraindications Summary

Drug	Hard Contraindications
ACEi	Pregnancy, angioedema, hyperkalemia, bilateral renal artery stenosis
ARB	Pregnancy, hyperkalemia, bilateral renal artery stenosis
Non-DHP CCB	AV block grade 2-3, severe LV dysfunction
Thiazides	Gout
Beta-blockers	Asthma, AV block grade 2-3
MRAs (spironolactone)	Hyperkalemia, creatinine >2.5 mg/dL (men) or >2.0 mg/dL (women)

Key Takeaways

Most patients need at least 2 drugs - don't wait with monotherapy if BP is significantly elevated
Foundation of therapy: RAS blockade (ACEi or ARB) is the backbone for most patients
Single-pill combinations improve adherence significantly
Lifestyle modification is always concurrent with medications, not replaced by them
Each 5 mm Hg reduction in SBP corresponds to ~10% reduction in cardiovascular events

Sources: Comprehensive Clinical Nephrology 7th Ed.; Goldman-Cecil Medicine; The Washington Manual of Medical Therapeutics; Goodman & Gilman's Pharmacological Basis of Therapeutics

Disclaimer: This is educational information only. Antihypertensive treatment should be individualized by a healthcare provider based on the patient's full clinical picture, comorbidities, and lab values.

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