The foundation of modern therapy relies on A (ACEi/ARB), C (CCB), and D (Thiazide/Like Diuretics). The 2024 guidelines heavily favour initiating with a Fixed Dose Combination (FDC) containing two drugs at low doses rather than maximising monotherapy. This rapidly achieves control, reduces adverse effects, and massively improves patient adherence.
2. Resistant vs. Refractory Hypertension
Resistant: BP remains above target despite concurrent use of 3 antihypertensive agents of different classes (including a diuretic) at optimal doses. Add an MRA (Spironolactone).
Refractory: BP remains uncontrolled despite 5 or more agents (including a long-acting thiazide and an MRA). Requires immediate specialist referral for secondary cause evaluation.
⏱ Pharmacokinetics: Time to Full Effect
| Drug Class | Expect Full Effect In… |
|---|---|
| Alpha Blockers | 1 – 2 days |
| Calcium Channel Blockers | 4 – 5 days |
| Thiazides & Clonidine | 1 week |
| ACE Inhibitors & ARBs | 3 weeks |
| Spironolactone (MRA) | 4 – 6 weeks |
| Beta Blockers | Variable (Monitor via HR reduction) |
📈 Standardised BP Measurement Protocol
Inaccurate measurement is the primary cause of misdiagnosis and inappropriate titration. Ensure the following:
| Patient Prep | Rest for 5 mins. Empty bladder. No coffee/smoking for 30 mins prior. |
| Positioning | Seated, back supported. Arm resting on a table at mid-heart level. Legs uncrossed. |
| Cuff Size | Must encircle 75-100% of the arm. Small cuffs falsely overestimate BP. |
| Technique | Take 3 measurements, 1-2 mins apart. Discard the 1st reading and average the 2nd and 3rd. |
🍎 Evidence-Based Lifestyle Interventions
| Intervention | Target Goal | Approx. SBP Drop |
|---|---|---|
| Weight Loss | Maintain normal BMI / optimal waist circ. | ~1 mmHg / kg lost |
| Healthy Diet | DASH diet (rich in veg/fruit/whole grains) | ~11 mmHg |
| Dietary Sodium | < 1500 mg/day (or 1000 mg reduction) | ~5 – 6 mmHg |
| Dietary Potassium | Target 3500-5000 mg/day (Caution in CKD) | ~4 – 5 mmHg |
| Physical Activity | 90-150 min/week moderate aerobic exercise | ~5 – 8 mmHg |
Algorithm References & Evidence Base
- McEvoy JW, et al. 2024 ESC Clinical Practice Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024.
- Unger T, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020.
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