What are the first-line treatment options for hypertension?

From the Guidelines

First-line treatment options for hypertension should include ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics, as these have demonstrated the most effective reduction of BP and CVD events, according to the 2024 ESC guidelines 1. The choice of medication should be individualized based on comorbidities, age, race, and potential side effects.

• For patients with diabetes or chronic kidney disease, ACE inhibitors or ARBs are preferred, as they have been shown to reduce the risk of progressive kidney disease 1.
• In patients with established coronary artery disease, ACE inhibitors or ARBs are recommended first-line therapy for hypertension 1.
• Calcium channel blockers or thiazide diuretics may be more effective in Black patients.
• Many patients will require two or more medications to achieve target blood pressure goals of less than 130/80 mmHg. Some key points to consider when selecting a medication include:
• The mechanism of action: diuretics reduce blood volume, ACE inhibitors and ARBs relax blood vessels by affecting the renin-angiotensin system, calcium channel blockers prevent calcium from entering heart and blood vessel cells, and beta-blockers reduce heart rate and cardiac output.
• Potential side effects: ACE inhibitors and ARBs can cause hyperkalemia and acute kidney injury, while calcium channel blockers can cause edema and constipation.
• Combination therapy: the 2024 ESC guidelines recommend combination therapy with a RAS blocker (either an ACE inhibitor or an ARB) and a dihydropyridine CCB or diuretic as initial therapy for most patients with confirmed hypertension 1. It is also important to consider lifestyle modifications, such as reducing sodium intake, adopting the DASH diet, regular physical activity, weight loss, limiting alcohol consumption, and smoking cessation, as these can help to lower blood pressure and reduce the risk of cardiovascular disease. The 2024 ESC guidelines also recommend fixed-dose single-pill combination treatment for patients receiving combination BP-lowering treatment, as this can improve adherence and reduce the risk of cardiovascular events 1. Overall, the goal of treatment should be to achieve a blood pressure target of less than 130/80 mmHg, while minimizing the risk of adverse effects and improving quality of life.

From the FDA Drug Label

Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

The first-line treatment options for hypertension include a variety of pharmacologic classes, such as:

• Losartan 2
• Lisinopril 3 It is recommended to follow published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), for specific advice on goals and management. Key considerations for selecting therapy include:
• The patient's absolute risk
• Additional approved indications and effects of the drug
• Potential for combination therapy, as many patients will require more than one drug to achieve blood pressure goals.

From the Research

First-Line Treatment Options for Hypertension

The first-line treatment options for hypertension include several classes of medications, with the choice of medication depending on various factors such as the patient's overall health, medical history, and the presence of any comorbid conditions.

• Angiotensin-Converting Enzyme (ACE) Inhibitors: ACE inhibitors are commonly used to treat hypertension, but the evidence suggests that they may not be the best first-line option for all patients 4, 5. They work by inhibiting the conversion of angiotensin I to angiotensin II, which causes blood vessels to constrict and blood pressure to increase.
• Angiotensin Receptor Blockers (ARBs): ARBs are an alternative to ACE inhibitors and have been shown to be equally effective in reducing blood pressure, with fewer side effects 5, 6. They work by blocking the action of angiotensin II on its receptors, which also helps to relax blood vessels and lower blood pressure.
• Calcium Channel Blockers: Calcium channel blockers are another option for first-line treatment of hypertension, particularly in elderly patients 7. They work by blocking the entry of calcium into muscle cells, which helps to relax blood vessels and lower blood pressure.
• Diuretics: Diuretics, such as thiazide diuretics, are also commonly used to treat hypertension, especially in patients with mild to moderate hypertension 7. They work by increasing urine production, which helps to remove excess fluid from the body and lower blood pressure.

Comparison of Treatment Options

Studies have compared the efficacy and safety of different treatment options for hypertension. For example, a study found that ACE inhibitors and ARBs had similar efficacy in reducing blood pressure, but ARBs had fewer side effects 5. Another study found that calcium channel blockers and diuretics were more effective than ACE inhibitors and beta-blockers in lowering systolic blood pressure in elderly patients 7.

Considerations for Treatment

When choosing a first-line treatment option for hypertension, healthcare providers should consider various factors, including the patient's medical history, comorbid conditions, and potential side effects of the medication. For example, ACE inhibitors may not be suitable for patients with certain medical conditions, such as kidney disease or heart failure 8. Similarly, ARBs may be a better option for patients who experience side effects with ACE inhibitors 6.