Treating Hypertension (HTN)

When left untreated or undertreated, hypertension (HTN), also called high blood pressure, increases risk for heart disease, stroke, and kidney failure. The primary goal of treatment is to lower blood pressure to healthier levels to reduce the risk of long-term cardiovascular damage. Treatments fall into two broad categories: lifestyle changes and medication, and are used separately or in combination depending on the severity of the condition and each person’s overall health. Using medications alone without incorporating any lifestyle modifications is akin to reading only the Old Testament or New Testament.

The Winter 2025 “To Your Health” column addressed accurately diagnosing HTN. When your properly measured systolic blood pressure is greater than or equal to 140 or the diastolic blood pressure is greater than or equal to 90, you have HTN. Family physicians and other primary care doctors diagnose and treat most HTN. Both the American Academy of Family Physicians and the American College of Physicians endorse 140/90 as the cutoff for average-risk people. Having certain medical conditions (e.g., heart failure, kidney transplant, known ischemic heart disease, or chronic kidney disease stages 3, 4, or 5, especially if there is protein in the urine) may make 130/80 a better target. The American Heart Association and American College of Cardiology prefers a cutoff of 130/80 for nearly all people.

This difference stems from the types of patients included and excluded in key studies used to set thresholds. Using the lower threshold of 130/80 instead of 140/90 as the cutoff for HTN resulted from: 1) data from sicker people being extrapolated to and generalized to all people; and 2) having a greater tolerance level for medication side effects that can occur when treating HTN more aggressively. My approach is 140/90 for average-risk people and 130/80 for those with co-morbid contusion that increase risk.

1. Lifestyle Modifications

Even when they do not normalize blood pressure (BP), the follwoing can decrease the amount of medication needed and improve general health and well-being.

a. Dietary Adjustments

The DASH (Dietary Approaches to Stop Hypertension) diet is one of the most effective dietary interventions—DASH Eating Plan | NHLBI, NIH. It emphasizes eating more fruits, vegetables, whole grains, and lean proteins while decreasing sodium, sugar, and unhealthy fats. Reducing sodium intake to less than 2,300 mg per day can decrease BP, especially in those whose HTN is more salt-sensitive. Potassium intake of 3,200-5,000 mg daily and magnesium intake of 370 mg to 600 mg daily can also help BP. Potassium-rich foods (e.g., bananas, spinach, legumes, broccoli, walnuts, and sweet potatoes) can help balance the negative effects of sodium. Magnesiumrich foods include dark chocolate, avocados, spinach, legumes, bananas, and salmon.

b. Exercise

Regular physical activity is critical for good general health and helps improve BP. Exercise strengthens the heart, allowing it to pump blood more efficiently, which can reduce the pressure on the arteries. The goal is 150 minutes weekly of moderate-intensity aerobic exercise (e.g., walking, cycling, or swimming) along with 2-3 sessions of resistance training (e.g., Pilates, plyometrics, resistance bands, kettlebells, or dumbbells).

c. Weight Management

Healthy weight is another key factor in controlling HTN. Elevated weight increases the workload on the heart and raises BP. Modest weight loss of 5-10% of body weight can help lower BP (and cholesterol and sugar and some arthritic pains).

d. Limit Alcohol and Quit Smoking

Excessive alcohol drinking is associated with higher BP; decreasing intake can help lower it. Men should drink no more than two drinks daily, while women should limit it to one drink daily. Smoking causes immediate spikes in BP and damages blood vessel walls. Therefore, quitting reduces the risk of heart disease and stroke by decreasing BP and other mechanisms.

e. Stress Reduction

Chronic stress can contribute to elevated BP. Prayer, mindfulness, deep breathing exercises, relaxation, and adequate sleep can help lower stress levels, which can improve BP.

2. Medicines for HTN

Medicines are prescribed when lifestyle changes alone are insufficient to reach BP goals. There are several classes of drugs used commonly to treat HTN, each working through different mechanisms.

a. Diuretics

Sometimes called “water pills,” diuretics help the body eliminate excess sodium and water through urine, reducing the volume of blood that needs to be pumped, which lowers BP. Common examples include thiazides (e.g., hydrochlorothiazide, chlorthalidone), loop diuretics (e.g., furosemide), and potassium-sparing diuretics (e.g., spironolactone, eplerenone).

b. ACEi (Angiotensin-Converting Enzyme Inhibitors)

ACEi work by blocking the production of angiotensin II, a hormone that causes blood vessels to constrict. By relaxing blood vessels, ACEi lower BP. Common examples include lisinopril, enalapril, and ramipril. About 10-30% of people develop a dry cough and need to switch to another medication. Less than 1% get angioedema, a severe allergic reaction that results in swelling in the tissues below your skin. It can be life threatening and occurs 5 times more often in people of African descent.

c. ARB (Angiotensin II Receptor Blockers)

ARB block the effects of angiotensin II directly at its receptors, preventing blood vessel constriction. Common examples include losartan, valsartan, and candesartan. ARB are less likely to cause cough or angioedema. Many people who get a cough on ACEi are switched successfully to ARB.

d. Calcium Channel Blockers

These medications prevent calcium from entering the muscle cells of the heart and blood vessels, leading to relaxation and lower BP. Common examples include amlodipine, diltiazem, and verapamil; the latter two also decrease heart rate.

e. Beta-Blockers

Beta-blockers reduce heart rate and the force of heartbeats, which lowers BP. These are typically not first-line drugs and are used when other drugs are ineffective or when a patient has additional heartrelated conditions or other health problems that might benefit from beta-blockers, e.g., migraine or chronic headache and some tremors. Examples include metoprolol, atenolol, and propranolol.

f. Other Medications

Additional classes of anti-HTN drugs include direct renin inhibitors (e.g., aliskiren), alphablockers, and vasodilators, which are prescribed in very specific situations or combined with other medications to improve BP.

g. Combination Therapy

There are pills that contain two drugs, which make adherence easier and replaces two co-pays with one. Three-in-one combinations are in the works.

Effective management of HTN involves both lifestyle and medication therapies. Living a healthy lifestyle, adhering to prescription medication, and monitoring BP regularly can significantly reduce risks associated with HTN and improve your health outcome and quality of life.

Dr. Stephen A. Wilson, MD, MPH, FAAFP, is Chair of Family Medicine at Boston University Chobanian and Avedisian School of Medicine and Chief of Family Medicine for Boston Medical Center.

1 https://www.nhlbi.nih.gov/education/dash-eating-plan