Along with regular assessments and lifestyle modifications, the key treatment for primary (essential) hypertension lies in selecting the right course of antihypertensive medication or following a combination treatment regimen to lower blood pressure more effectively. In this article, we break down the treatments that are recommended as per ACC/AHA guidelines.

Pharmacologic therapy- Who should be given this treatment?

Patients with an out-of-office daytime blood pressure of >135 mmHg systolic or >85 mmHg diastolic (or an average office blood pressure of >140 mmHg systolic or >90 mmHg diastolic if out-of-office values are unavailable). Patients with an out-of-office blood pressure of >130 mmHg systolic or >80 mmHg diastolic (or, if out-of-office measurements are unavailable, the average of accurately measured office readings of >130 mmHg systolic or >80 mmHg diastolic) who exhibit one or more of the following characteristics:

• Clinical cardiovascular illness that has been established eg, chronic coronary syndrome (stable ischaemic heart disease), heart failure, carotid disease, previous stroke, or peripheral arterial disease
• Diabetes, type 2
• Chronic renal disease
• 65 years of age or older
• A risk of atherosclerotic cardiovascular disease of at least 10% during a ten-year period

However, research on the risks and benefits of starting antihypertensive therapy in patients with stage 1 hypertension (130 to 139 mmHg systolic and 80 to 89 mmHg diastolic) who are over the age of 75 or who have a 10-year risk of atherosclerotic cardiovascular disease of at least 10% is limited (but no clinical cardiovascular disease, diabetes, or chronic kidney disease). A tailored strategy with shared decision-making for these specific patient populations should be preferred.

Choice of first antihypertensive medicines 

Numerous recommendations and meta-analyses show that the degree of blood pressure decrease, rather than the antihypertensive medicine used, is the primary predictor of cardiovascular risk reduction in people with hypertension.

In individuals with diabetic nephropathy or non-diabetic chronic kidney disease, especially when exacerbated by proteinuria, an ACE inhibitor or an ARB should be administered as the first monotherapy.

Beta-blockers are no longer advised as first-line therapy unless there is a particular (compelling) rationale, such as ischemic heart disease or heart failure with low ejection fraction.

Combination treatment 

1. In most individuals whose baseline systolic blood pressure is 15 mmHg or more above their goal, single-agent therapy will not be enough to reduce blood pressure. Combination treatment with medications from multiple classes lowers blood pressure far more effectively than doubling the dose of a single medication, with fewer adverse effects.
   1. Combining a long-acting ACE inhibitor or ARB with a long-acting dihydropyridine calcium channel blocker is recommended when more than one drug is needed to regulate blood pressure.
   2. When using hydrochlorothiazide, combining an ACE inhibitor or ARB with a thiazide diuretic may be less effective. It is not recommended to take ACE inhibitors and ARBs at the same time.
2. Any patient whose blood pressure is higher than 20 mmHg systolic or 10 mmHg diastolic above their target blood pressure should receive initial combination antihypertensive treatment with two first-line medicines from different classes.
   1. If blood pressure remains uncontrolled after the use of two antihypertensive drugs, an ACE inhibitor or ARB in combination with both a long-acting dihydropyridine calcium channel blocker and a thiazide-like diuretic (chlorthalidone preferred) is suggested.
   2. If a long-acting dihydropyridine calcium channel blocker causes leg oedema, a non-dihydropyridine calcium channel blocker (such as verapamil or diltiazem) can be administered instead.
   3. A mineralocorticoid receptor antagonist (such as spironolactone or eplerenone) may be used if a thiazide-like diuretic is not tolerated or is contraindicated.
3. If the above-mentioned medication classes are incompatible or contraindicated, beta-blockers, alpha-blockers, or direct arterial vasodilators are other alternatives. Generally, beta-blockers and non-dihydropyridine calcium channel blockers should not be used together.
4. When possible, fixed-dose, single-pill combination drugs should be utilised to alleviate patients' pill burden and promote treatment adherence.
5. Patients who do not get adequate control of their blood pressure with a combination of three antihypertensive drugs given in acceptable dosage and with a diuretic are deemed to have drug-resistant hypertension (once nonadherence and white coat effect have been eliminated as possibilities).

What are the nonpharmacologic treatments for hypertension?

1. Dietary salt restriction - Modest sodium restriction results in a 4.8/2.5 and 1.9/1.1 mmHg decrease in blood pressure in hypertensive and normotensive people, respectively.
2. Potassium supplementation - This is done ideally by dietary adjustment unless prohibited by chronic renal illness or the use of potassium-depleting medications.
3. Weight loss - In overweight or obese individuals, weight reduction can result in a considerable drop in blood pressure that is independent of activity. The decrease in blood pressure caused by weight reduction typically varies between 0.5 and 2 mmHg for every kilogram removed.
4. DASH diet - The Dietary Approaches to Stop Hypertension (DASH) diet emphasises vegetables, fruits, low-fat dairy products, whole grains, chicken, fish, and nuts while avoiding sweets, sugar-sweetened drinks, and red meat.
5. Exercise - Aerobic, dynamic resistance and isometric resistance exercise all have the potential to reduce systolic and diastolic blood pressures by an average of 4 to 6 mmHg and 3 mmHg, respectively, regardless of weight reduction.
6. Moderate alcohol consumption - Adult men and women with hypertension should consume no more than one or two alcoholic beverages daily.

Blood pressure targets 

The following recommendations for target blood pressure are based on the patient's baseline risk of having a cardiovascular event; these recommendations largely align with those given by the 2017 ACC/AHA guidelines.

1. In the majority of patients who qualify for antihypertensive pharmacologic treatment, a target blood pressure of 130 mmHg systolic and 80 mmHg diastolic should be achieved using out-of-office readings.
2. A less aggressive objective <135 mmHg systolic and <85 mmHg diastolic blood pressure (using out-of-office measurement) or <140 mmHg systolic and <90 mmHg diastolic blood pressure is prefered in the following categories of hypertensive patients:
   1. Patients with labile blood pressure or postural hypotension
   2. Patients experiencing adverse effects from several antihypertensive drugs
   3. Patients 75 years of age or older who have a significant burden of comorbidity or have a diastolic blood pressure of less than 55 mmHg
3. In older adults with severe frailty, dementia, and/or a short life expectancy, as well as in patients who are non-ambulatory or institutionalised (e.g., in a skilled nursing facility), goals should be tailored and collaborated with the patient, relatives, and caregivers, rather than focusing on one of the blood pressure targets mentioned above.

Once a blood pressure target has been established for an individual patient, it should be documented in the patient's medical record, communicated to the patient explicitly, and conveyed to other members of the healthcare team. At each appointment, it should be determined whether or not blood pressure is within the target range.

After initiating antihypertensive treatment, patients should be assessed periodically and medication increased incrementally until sufficient blood pressure control is obtained. After achieving blood pressure management, patients should be monitored every three to six months to maintain continuous control.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.