What is the first-line treatment for hypertension?

From the Guidelines

The first-line treatment for hypertension should be a combination of lifestyle modifications and medication, with ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics being the recommended first-line medications, as they have demonstrated the most effective reduction of BP and CVD events 1. When initiating treatment, it's essential to consider the patient's characteristics, comorbidities, and potential side effects. Here are the key recommendations:

• Start with lifestyle changes:
  1. Reduce sodium intake to less than 2,300 mg per day
  2. Adopt the DASH diet (rich in fruits, vegetables, and low-fat dairy)
  3. Exercise regularly (150 minutes of moderate-intensity aerobic activity per week)
  4. Limit alcohol consumption
  5. Maintain a healthy weight
  6. Quit smoking
• If blood pressure remains elevated after 3-6 months of lifestyle changes, or if initial blood pressure is severely high, medication should be initiated with:
  1. ACE inhibitors (e.g., lisinopril 10-40 mg daily)
  2. Angiotensin receptor blockers (e.g., losartan 50-100 mg daily)
  3. Dihydropyridine CCBs (e.g., amlodipine 5-10 mg daily)
  4. Diuretics (thiazides and thiazide-like drugs such as chlorthalidone and indapamide) Combination therapy with a RAS blocker (either an ACE inhibitor or an ARB) and a dihydropyridine CCB or diuretic is recommended for most patients with confirmed hypertension as initial therapy 1. It's crucial to monitor blood pressure and kidney function regularly and adjust the treatment regimen as needed to achieve optimal blood pressure control. In patients receiving combination BP-lowering treatment, fixed-dose single-pill combination treatment is recommended 1. If BP is not controlled with a two-drug combination, increasing to a three-drug combination is recommended, usually a RAS blocker with a dihydropyridine CCB and a thiazide/thiazide-like diuretic, and preferably in a single-pill combination 1.

From the Research

First-Line Treatment for Hypertension

The first-line treatment for hypertension typically involves a combination of lifestyle modifications and medication.

• Lifestyle modifications include:
  • Weight loss
  • Healthy dietary pattern with low sodium and high potassium intake
  • Physical activity
  • Moderation or elimination of alcohol consumption
• First-line drug therapy for hypertension consists of:
  • Thiazide or thiazide-like diuretics such as hydrochlorothiazide or chlorthalidone 2
  • Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers such as enalapril or candesartan 2, 3
  • Calcium channel blockers such as amlodipine 2, 4

Medication Options

Different studies suggest various medication options as first-line treatment for hypertension:

• Thiazide diuretics, such as chlortalidone, are considered a first-choice treatment for hypertension in adults without diabetes or cardiovascular or renal disease 5
• ACE inhibitors, such as lisinopril, can be used as first-step agents in the treatment of hypertension 3
• Amlodipine, a calcium channel blocker, has been shown to be effective in improving blood pressure and patient outcomes, and can be considered a first-line antihypertensive agent 4, 6

Treatment Goals

The goal of treatment is to achieve a blood pressure target of:

• Less than 130/80 mmHg for adults under 65 years 2
• Less than 130 mmHg for adults 65 years and older 2