Management of Hypertension in Primary Care – Key Points
Management of Hypertension in Primary Care – Key Points
Medscape : Douglas S. Paauw, August 15, 2025
– University of Washington (Primary Care & Medical Education). Based on: 2025 AHA/ACC Guideline for the Management of Hypertension in Adults (Circulation & JACC, Aug 14, 2025) and ESC Guidelines 2024 on Hypertension:
1. Secondary Hypertension – Most Common Causes
• Essential hypertension = 90–95% of cases.
• More common secondary causes:
* Obstructive sleep apnea: 25–50%
* Hyperaldosteronism: 8%
* Atherosclerotic renal artery stenosis: 5%
* Drug/alcohol abuse: 4%
• Rare causes (e.g., pheochromocytoma, coarctation, Cushing’s) = <0.1%.
2. Initial Treatment of Newly Diagnosed Hypertension
• If BP >20/10 mmHg above target → start two-drug therapy.
• Stage 1 hypertension (mild elevation) → usually starts with one drug.
3. When One Drug Fails to Achieve the Target
• Doubling the dose of a single drug lowers BP only slightly (e.g., valsartan 80 → 160 mg = ↓3/0.8 mmHg).
• Adding a second drug (e.g., hydrochlorothiazide) gives a greater effect (↓12/6 mmHg).
• Meta-analysis: combination therapy lowers BP ~5x more than dose doubling.
4. Resistant Hypertension – Modern Approach
• First step: assess adherence, as up to 80% of patients take fewer drugs than prescribed.
• If true resistant hypertension (≥3 drugs, documented adherence):
* Spironolactone lowers SBP by 16 mmHg / DBP by 9 mmHg.
* Amiloride shown to be equivalent to spironolactone (SBP reduction ~13.6 mmHg).
• MRAs(Mineralocorticoid receptor antagonists) recommended by ACC/AHA guidelines.
5. Clinical Pearls
• Always consider sleep apnea and hyperaldosteronism as leading secondary causes.
• Two drugs are better than one in most patients.
• Spironolactone (or amiloride) is the best add-on for resistant hypertension.
