What is the diagnosis and first-line treatment of essential hypertension?

From the Guidelines

Essential hypertension is diagnosed when a patient has persistently elevated blood pressure (BP) readings of ≥140/90 mmHg, and first-line treatment typically includes lifestyle modifications and medication therapy with ACE inhibitors or angiotensin receptor blockers (ARBs) as preferred options, especially for patients with diabetes or chronic kidney disease. Diagnosis requires at least two separate office visits with elevated readings, or through 24-hour ambulatory BP monitoring or home BP monitoring 1. Lifestyle changes include adopting a healthy diet, reducing sodium intake, regular physical activity, weight loss if overweight, limiting alcohol consumption, and smoking cessation.

For pharmacological treatment, the choice of medication depends on patient characteristics, but ACE inhibitors or ARBs are recommended as first-line options, with a goal to achieve blood pressure targets and reduce cardiovascular events 1. According to the standards of medical care in diabetes-2018, treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes, such as ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers 1.

Some key points to consider in the treatment of essential hypertension include:

• Patients with confirmed office-based blood pressure ≥160/100 mmHg should have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes 1.
• Combinations of ACE inhibitors and ARBs and combinations of ACE inhibitors or ARBs with direct renin inhibitors should not be used 1.
• For patients treated with an ACE inhibitor, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually 1.

Overall, the goal of treatment is to achieve blood pressure targets and reduce the risk of cardiovascular events, with a focus on individualized care and regular monitoring to assess efficacy and adjust therapy as needed.

From the FDA Drug Label

In controlled clinical studies of patients with mild to moderate hypertension, patients were treated with lisinopril 20 mg to 80 mg daily, hydrochlorothiazide 12. 5 mg to 50 mg daily or atenolol 50 mg to 200 mg daily; and in other studies of patients with moderate to severe hypertension, patients were treated with lisinopril 20 mg to 80 mg daily or metoprolol 100 mg to 200 mg daily.

The diagnosis of essential hypertension is not directly addressed in the provided drug labels. However, the first line treatment for essential hypertension can be Lisinopril or Amlodipine.

• Lisinopril is an ACE inhibitor that has been shown to be effective in reducing blood pressure in patients with mild to moderate hypertension.
• Amlodipine is a calcium channel blocker that has been shown to be effective in reducing blood pressure and preventing hospitalizations for angina and revascularization procedures in patients with coronary artery disease. The choice of first line treatment depends on various factors, including the patient's medical history, lifestyle, and preferences. It is essential to consult with a healthcare professional to determine the best course of treatment for each individual patient 2, 3.

From the Research

Diagnosis of Essential Hypertension

• Essential hypertension is defined as persistent systolic blood pressure (SBP) at least 130 mm Hg or diastolic BP (DBP) at least 80 mm Hg 4
• Blood pressure screening using an office-based measurement is recommended for adults 18 years and older without a history of hypertension 5
• Home BP monitoring and ambulatory BP monitoring are beneficial in patients for whom there is a concern for masked or white-coat hypertension 5

First Line Treatment

• First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern that includes low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption 4
• The Dietary Approaches to Stop Hypertension (DASH) diet is the most effective dietary modification 5
• First-line drug therapy for hypertension consists of a thiazide or thiazidelike diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker 4, 5
• Thiazide diuretics, such as chlortalidone or hydrochlorothiazide, are often the first choice for treatment 6
• Angiotensin-converting enzyme inhibitors, such as captopril, lisinopril, or ramipril, are also effective options 6
• Calcium channel blockers, such as amlodipine, are also used as first-line treatment 4, 5

Treatment Goals

• The goal of treatment is to achieve a systolic blood pressure (SBP) of less than 130 mm Hg and a diastolic blood pressure (DBP) of less than 80 mm Hg 4
• Intensive blood pressure control, defined as a systolic blood pressure of less than 120 mm Hg, may be beneficial for patients with elevated risk, but may also increase the risk of adverse effects 5
• The decision to initiate antihypertensive medication should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 4