Management of primary hypertension

Silent killer Posted by Ahmad Azizov on April 05, 2021


A blood pressure (BP) measurement is made up of two values, one being systolic and the other being diastolic. Normal BP is <120 systolic and <80 diastolic. Elevation in BP is categorized into different stages that can be managed accordingly. This article discusses the management of primary or essential hypertension which is not caused by any identifiable disease processes but rather happens on its own. 

Table 1. Blood pressure stages
Stage Systolic Diastolic Management
Normal <120 <80 Annual follow up
Elevated BP <130 <80

Lifestyle changes

  • Diet
    • NaCl reduction (<2.4g/day)
    • DASH (Dietary Approaches to Stop Hypertension) diet
    • Etoh reduction (2 for men, 1 for women /day)
  • Exercise 
    • 30 mins a day, 4 times a week
  • Weight loss
    • BMI<25

Follow up every 6 months

Stage 1 <140 <90

Lifestyle changes as above

Medical treatment if there are other risk factors

  • Smoking 
  • Dyslipidemia 
  • Family history 
  • Diabetes 
  • Obesity 
  • Male >45 and Female >55
  • HTN resistant to lifestyle changes

Follow up after 1 month 

  • Important for titration and side effects 
  • Need 2 visits, 2 weeks apart with 2 readings to diagnose
  • Home blood pressure monitoring can be very helpful 
Stage 2 >140 >90

Lifestyle changes as above

Two medications 

  • Depend on the other comorbidities

Follow up after 1 month 

  • Titration and diagnosis 
  • Home blood pressure monitoring 
Hypertensive urgency >180 >120

No end-organ damage 

IV antihypertensives and then oral

Hypertensive emergency >180 >120

End organ damage present 

  • Elevated Cr
  • Altered mental state
  • SOB 
  • CP or elevated troponin
  • Elevated liver enzymes

Start on IV antihypertensives

  • Reduce MAP ~25% for 2-6 hrs
  • Oral antihypertensives after



There are many different classes of antihypertensives and what determines which one you should use depends on the patients' other comorbidities. Another important factor with antihypertensives is to titrate the dose effectively to avoid hypotension:

Comorbidities Medications Examples









ACE + thiazide diurethic


ACEi/ARB (except in stage 4)

Hydralazine (Stage 5)




No other comorbidity


Calcium channel blocker 



Medication uses and side effects by class 

  • Calcium channels 
    • Uses 
      • Angina 
    • Dihydropyridines 
      • Peripheral edema
    •  Non-dihydropyridines 
      • Verapamil
      • Diltiazem 
      • Uses
        • AFib for rate control
  • ACEi/ARB
    • Creatinine elevation >20%
    • Cough and angioedema (ACEi only)
    • Hyperkalemia 
  • Thiazide 
    • Uses
      • Kidney stones by reducing urinary calcium
    • Decreased potassium 
  • Beta-blockers 
    • Decreased heart rate 
  • Aldosterone antagonists 
    • Uses 
      • Resistant hypertenison 
      • CHF class 3
    • Hyperkalemia 
    • Gynecomastia 
  • Dilaters 
    • Arterial 
      • Uses
        • Stage 5 CKD
      • Hydralazine
        • Reflex tachycardia 
        • Drug-induced lupus 
    • Venous 
      • Nitrate 
        • Uses
          • Angina
        • Don't use with other nitrates 
        • Don't use with PDE-i 
  • Alpha-antagonists 
    • Generally used for BPH
    • Can lead to orthostatic hypotension 
  • Central acting meds 
    • Clonidine 
      • Rebound hypertension 
      • Can use the transdermal patch to avoid hypertension issues

All information provided on this website is for educational purposes and does not constitute any medical advice. Please speak to you doctor before changing your diet, activity or medications. 

Written by
Ahmad Azizov Member since April 2020
Interested in Vascular surgery resident at Western U

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