What is the recommended initial antihypertensive medication for a patient newly diagnosed with hypertension?

From the Guidelines

For a newly diagnosed hypertensive patient, thiazide diuretics, calcium-channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers are recommended as first-line therapy, with the choice depending on individual patient factors including age, race, and comorbidities, as stated in the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. When selecting a medication, it's crucial to consider the patient's specific characteristics.

• For most adults, thiazide diuretics (especially chlorthalidone) and calcium-channel blockers are preferred options due to their efficacy 1.
• In black patients, including those with diabetes, thiazide diuretics and calcium-channel blockers are recommended as first-line agents, whereas β-blockers and renin–angiotensin system inhibitors are less effective at lowering blood pressure 1.
• Patients with diabetes or kidney disease may benefit more from an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker, which can help reduce cardiovascular risk and slow disease progression 1. The goal of treatment is to achieve a blood pressure target of less than 130/80 mm Hg, with lifestyle modifications also playing a critical role in managing hypertension, including reducing sodium intake, maintaining a healthy weight, regular exercise, limiting alcohol, and following a DASH diet 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION 2. 1 Hypertension Initial Therapy in adults: The recommended initial dose is 10 mg once a day. The patient newly diagnosed with hypertension should take lisinopril (PO) with an initial dose of 10 mg once a day 2.

• The dosage should be adjusted according to blood pressure response.
• The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose.

From the Research

Hypertension Medication Options

A patient newly diagnosed with hypertension has several medication options to consider. The choice of medication depends on various factors, including the level of blood pressure and the presence of other health conditions.

• First-line therapy for hypertension consists of:
  • Thiazide or thiazide-like diuretics, such as hydrochlorothiazide or chlorthalidone 3
  • Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, such as enalapril or candesartan 3
  • Calcium channel blockers, such as amlodipine 3
• According to the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), thiazide-type diuretics are superior in preventing major forms of cardiovascular disease and are less expensive 4
• The ALLHAT study also found that chlorthalidone, a thiazide-type diuretic, was superior to amlodipine, lisinopril, and doxazosin in preventing heart failure 5

Considerations for Medication Selection

When selecting a medication, it's essential to consider the patient's individual needs and health status. For example:

• Patients with diabetes or previous cardiovascular disease may require more aggressive blood pressure control 6
• Patients with chronic kidney disease or atherosclerotic cardiovascular disease may require specific medications or dosing regimens 7
• The choice of medication may also depend on the patient's age, sex, and other demographic factors 7

Real-World Evidence

Real-world evidence suggests that there is significant variation in initial antihypertensive prescribing, and there are gaps between current guideline recommendations and real-world implementation in early hypertension care 7