One of the first steps in controlling hypertension is measuring it correctly. Often, health care professionals are not aware of or follow the correct BP measurement guidelines. Clinicians should take BP in both upper extremities, especially during a first visit, so they can be compared. If the results are unequal, they should pay careful attention to the higher value. Patients who visit a cardiologist or their primary care physician should have their home BP measurements to compare with the BP taken by the health care provider. Let patients know they should ideally take their BP twice a day, especially 1 to 2 weeks prior to seeing a provider. The new hypertension guidelines recognize 5 new stages to hypertension. These are normal, elevated, HBP stage 1, HBP stage 2, and hypertensive crisis (see TABLE). These stages are based on diastolic and systolic blood pressure levels. Diastolic pressure refers to the pressure in the arteries when the heart rests, whereas systolic blood pressure refers to the pressure in the arteries when the heart beats. Normal systolic blood pressure level is lower than 120 mm Hg. Most patients fall into the stage 1 range of hypertension, especially if they are young. If BP is managed early and effectively, the patient can benefit tremendously and have a healthier heart and arteries. Unfortunately, many patients are in the hypertensive crisis zone for years and go untreated. Most do not have insurance, do not visit their providers, or are not adherent to the advised treatment options.2
To treat hypertension, the first step for patients with stage 1 or stage 2 is the use of nonpharmacological treatments. If these patients can follow lifestyle modifications, they may not even need BP medication. One of these recommended lifestyle changes is a low-sodium diet, with 1500 mg of sodium daily for patients on a medication and 2300 mg daily for those not taking any medications. Paying close attention to body mass index and weight control is another first-line recommendation for these patients. Aerobic exercise of 150 to 250 minutes per week, or 30 minutes a day, can stabilize BP effectively. Most patients are advised to follow their exercise routine every day and adjust per their life and work schedules. Staying consistent and following the routine daily is the key to effectively controlling hypertension. Another recommendation is to eat more fish, fruits, green vegetables, legumes, low-fat dairy products, and poultry. Patients should also consume less red meat, saturated and trans fats, and sugar-sweetened beverages and limit alcohol.3
Pharmacological treatment options are also available. According to the guidelines, first-line options for patients with HBP include the use of thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs). Patients 60 years or older should not use β-blockers as initial agents for BP control. Health care providers may use β-blockers for patients with coronary artery disease, dysrhythmias, ejection fraction, or heart failure.
The suggested protocol for managing moderate hypertension with 20 mm Hg above goal is to use ACE inhibitors, ARBs, with a diuretic or a dihydropyridine calcium channel blocker combination. Dihydropyridine calcium channel blockers include amlodipine, felodipine, and nifedipine. Patients should always start with a low dose and titrate to a higher dose. Among the diuretic options, thiazide diuretics are recommended as first-line therapies, whereas medications such as chlorthalidone may be used as a more potent option than hydrochlorothiazide. Subsequent options could include aldosterone blockers or vasodilating β-blockers. Vasodilating β-blockers include carvedilol and nebivolol. Finally, α-blockers and direct vasodilators are recommended if previous options at maxed-out dosages do not help with BP control.4
Clinicians must consider certain exceptions and factors when treating HBP. For Black patients, treatment with diuretics and calcium channel blockers should be the first options. Practitioners should put patients aged 18 to 75 years with chronic kidney disease on an ACE inhibitor or an ARB. Even in these categories of medications, some could be potent and some could be weak. Among ARBs, losartan is the weakest agent, requiring twice-daily dosing, whereas olmesartan and azilsartan are the most potent ARB agents. Among thiazide diuretics, chlorthalidone is more potent than. Therefore, if a patient has not responded to hydrochlorothiazide, consider chlorthalidone. For patients who have difficulty controlling hypertension despite using the appropriate treatment medications, health care professionals should ensure the patient is adherent to the medications, exercises regularly, and limits alcohol and sodium. If a patient is already taking a β-blocker for a different reason, changing the β-blocker to a more vasodilating option may help. Adding aldosterone blockers could be another option for patients whose HBP is not being controlled effectively despite using first-line therapy options.4
Clinicians must follow hypertension treatment guidelines for patients with hypertension and cardiac disease history, as well as for those with chronic conditions such as diabetes, dyslipidemia, and kidney disease. Having HBP for years not only affects and reduces heart function but can also worsen other comorbidities. Unless addressed in a timely fashion, these comorbidities can result in numerous emergency department visits and hospitalizations. From an economic standpoint, HBP costs the US health care sector about $131 billion annually. Practitioners must help patients manage the condition properly.1 Counsel patients about nonpharmacological treatment options first and then follow physicians’ advice about taking hypertension medications. Taking atherosclerotic cardiovascular disease risk and patient history into account, practitioners should individualize treatment for patients but also follow national hypertension guidelines.
Saro Arakelians, PharmD, is a vice president of pharmacy operations in Los Angeles, California.
Roger On, MD, is a physician at Heritage Provider Network in Los Angeles.
- Facts about hypertension. CDC. Updated September 8, 2020. Accessed November 24, 2020. https://www.cdc.gov/bloodpressure/facts.htm
- Understanding blood pressure readings. American Heart Association. Accessed November 24, 2020. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings
- Harsha DW, Bray GA. Weight loss and blood pressure control (Pro). Hypertension. 2008;51(6):1420-1425. doi:10.1161/HYPERTENSIONAHA.107.0940113
- Whelton PK, Carey RM, Aronow WS. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006