Hypertension treatment & referral

When to add medication

The usual treatment goal is <130/80 mm Hg, individualized for tolerance and clinical circumstances.

• Average BP ≥140/90: lifestyle measures plus medication; two first-line agents of different classes are preferred, ideally in one pill.
• Average BP ≥130/80 with CVD, prior stroke, diabetes, CKD, or PREVENT 10-year CVD risk ≥7.5%: add medication.
• Lower-risk stage 1: start lifestyle treatment; add medication if BP remains ≥130/80 after 3–6 months.

Lifestyle treatment belongs in every plan

Use a DASH-style eating pattern, reduce sodium, support healthy weight, encourage regular activity, limit or avoid alcohol, and address sleep and stress. Increase dietary potassium only when kidney function and medication-related hyperkalemia risk allow. Tobacco cessation reduces overall cardiovascular risk.

Choose achievable goals with the patient; lifestyle treatment continues after medication starts.^[9]

Understand the major medication classes

Select drugs around comorbidities and tolerance. HFrEF, pregnancy, advanced CKD, and symptomatic orthostasis need tailored plans.^[10][5]

Recognize true resistant hypertension

BP above goal despite three complementary agents at maximally tolerated doses, including a diuretic, or controlled BP requiring four or more drugs, warrants assessment for resistance. First exclude inaccurate measurement, white-coat effect, missed medication, and an inadequate regimen.

Optimize treatment and evaluate contributors before simply adding another pill. Refer to a hypertension specialist, cardiology, nephrology, or endocrinology according to the suspected cause.^[5]

Close the loop

After starting or changing therapy, arrange BP and symptom review, usually within about a month and sooner when risk warrants. Check renal function/electrolytes on a drug- and patient-specific schedule. Ask about dizziness, orthostasis, and adherence.

Specialist input is especially useful for confirmed resistance, suspected secondary disease, progressive kidney dysfunction, significant cardiac disease, or persistent treatment intolerance. Send the home log, cuff details, doses, labs, and prior responses.^[8]