What is the most appropriate initial antihypertensive treatment for a 47-year-old woman with stage 2 hypertension and a family history of heart disease?

From the Guidelines

The most appropriate treatment for this 47-year-old woman is chlorthalidone (option A). This patient has stage 2 hypertension with an average blood pressure of 142/96 mmHg over two years, requiring pharmacological intervention. According to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1, thiazide-type diuretics like chlorthalidone are recommended as first-line agents for uncomplicated hypertension. Chlorthalidone is particularly effective and has demonstrated superior cardiovascular outcomes compared to other antihypertensives in large clinical trials, as it works by inhibiting sodium reabsorption in the distal convoluted tubule, promoting sodium and water excretion, and reducing blood volume and peripheral resistance.

The evidence supports the use of chlorthalidone as a first-line treatment, with a systematic review and network meta-analysis conducted for the guideline suggesting that diuretics, especially chlorthalidone, may provide an optimal choice for first-step drug therapy of hypertension 1. Additionally, the prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline also recommends thiazide diuretics, especially chlorthalidone, as a preferred option for first-line therapy in most U.S. adults 1.

For this patient with no compelling indications for other agents (no heart failure, diabetes, or kidney disease), chlorthalidone would be the most appropriate initial choice. The other options - clonidine (central alpha-2 agonist), furosemide (loop diuretic), hydralazine (direct vasodilator), and spironolactone (aldosterone antagonist) - are not first-line treatments for uncomplicated hypertension and are typically reserved for specific indications or resistant hypertension.

Key points to consider in this patient's treatment include:

• The patient's average blood pressure of 142/96 mmHg over two years indicates stage 2 hypertension, requiring pharmacological intervention.
• The patient has no compelling indications for other agents, making chlorthalidone a suitable first-line treatment.
• Chlorthalidone has demonstrated superior cardiovascular outcomes compared to other antihypertensives in large clinical trials.
• The patient's family history of heart disease and BMI of 28 kg/m² increase her cardiovascular risk, making effective blood pressure management crucial.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Therapy should be initiated with the lowest possible dose. INDICATIONS AND USAGE Diuretics such as chlorthalidone are indicated in the management of hypertension either as the sole therapeutic agent or to enhance the effect of other antihypertensive drugs in the more severe forms of hypertension.

The most appropriate treatment at this time is chlorthalidone. The patient has an average blood pressure of 142/96 mmHg, which indicates hypertension. According to the drug label, chlorthalidone is indicated in the management of hypertension, and the recommended initial dose is 25 mg daily 2.

• The patient's blood pressure is elevated, and chlorthalidone is a suitable treatment option.
• The patient has no other medical conditions that would contraindicate the use of chlorthalidone.
• The patient's family history of heart disease increases her risk of cardiovascular complications, making it essential to manage her hypertension effectively.

Therefore, chlorthalidone (A) is the most appropriate treatment option for this patient 2.

From the Research

Treatment Options for Hypertension

The patient's average blood pressure of 142/96 mmHg over the past 2 years indicates hypertension, which is associated with an increased risk of cardiovascular disease events and death 3.

First-Line Therapy

First-line therapy for hypertension consists of lifestyle modification, including weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 3.

Pharmacologic Therapy

When pharmacologic therapy is required, first-line therapies include thiazide or thiazide-like diuretics, such as chlorthalidone, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blockers 3.

Choice of Diuretic

Head-to-head studies have shown trends favoring chlorthalidone as a more effective blood pressure lowering agent compared with hydrochlorothiazide, although statistical significance has not been consistently demonstrated 4, 5.

Treatment Decision

Given the patient's blood pressure and lack of comorbidities, the most appropriate treatment would be to initiate lifestyle modifications and consider pharmacologic therapy if necessary. Among the options provided, chlorthalidone is a suitable choice as a first-line diuretic for the treatment of hypertension 3, 4, 5.

• The most appropriate treatment at this time is:
  • A. chlorthalidone Other options, such as clonidine, furosemide, hydralazine, and spironolactone, are not typically considered first-line therapies for hypertension in this patient population 3, 6, 7.