Structured Approach to Hypertension Management: Stepwise Treatment and Medication Considerations

Step 1: Initial Assessment and Treatment Selection

1. Assessment:

   • Gather patient information, including medical history, age, ethnicity, comorbidities (such as diabetes), and current medications.
   • Measure blood pressure accurately using recommended techniques and devices.

2. Treatment Selection:

   • Identify the patient's profile based on age, ethnicity, and comorbidities according to guideline recommendations.
   • Choose initial medications:
     • ACE Inhibitors or ARBs for individuals with type 2 diabetes or aged under 55 but not of Black African or African–Caribbean origin.
     • Calcium-Channel Blockers (CCBs) for individuals aged 55 or over without type 2 diabetes or of Black African or African–Caribbean origin.
     • Consider alternatives like Thiazide-like Diuretics if initial medications are not tolerated.

Step 2: Treatment Adjustment for Uncontrolled Hypertension

3. Review and Adjustment:
   • Assess the effectiveness of Step 1 treatment after an appropriate period.
   • If hypertension remains uncontrolled, consider:
     • Adding a CCB or Thiazide-like Diuretic to the current medication regimen.
     • Evaluate patient response and potential side effects.

Step 3: Optimization and Combination Therapy

4. Optimization:
   • Review medication adherence and assess for any lifestyle modifications.
   • Adjust medication doses to achieve target blood pressure levels.
   • Consider combining medications from different classes if needed, based on patient response and tolerability.

Step 4: Addressing Resistant Hypertension

5. Identification of Resistant Hypertension:

   • Confirm elevated blood pressure through alternative measurements (ambulatory or home recordings).
   • Assess for potential causes of resistant hypertension, including adherence, lifestyle factors, and secondary causes.

6. Further Intervention:

   • Monitor for postural hypotension and discuss adherence with the patient.
   • Consider additional medications such as Spironolactone or seek specialist advice for resistant cases.
   • Evaluate for contraindications and side effects of added medications.

Key Considerations Throughout:

• Patient Education: Provide information on medications, lifestyle modifications, and the importance of adherence.
• Regular Monitoring: Schedule follow-up visits to monitor blood pressure, assess side effects, and evaluate treatment response.
• Individualized Approach: Tailor treatment plans based on patient characteristics, responses, and tolerances.
• Collaborative Care: Engage patients in shared decision-making and consider multidisciplinary approaches for complex cases.

Key Points to Watch Out For:

• Adherence: Ensure patients take medications as prescribed.
• Monitoring: Regularly monitor blood pressure and assess for side effects.
• Combination Therapies: Tailor combinations based on individual responses.
• Special Considerations: Check for contraindications, especially in pregnancy or certain ethnic groups.

These guidelines provide a structured approach to treating hypertension, emphasizing individualized care and a stepwise escalation based on treatment response and patient characteristics. Always consult with healthcare providers for specific medication recommendations and adjustments based on individual patient needs and considerations.