What is recommended for initiating a new antihypertensive medication for a patient?

From the Guidelines

Initiating antihypertensive medication should start with thiazide diuretics, calcium channel blockers (CCBs), or angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs) as first-line agents.

Recommended First-Line Agents

• Thiazide diuretics
• CCBs
• ACE inhibitors
• ARBs These recommendations are based on high-quality evidence from recent guidelines, including 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. The World Health Organization also recommends these classes of medications as initial treatment for adults with hypertension requiring pharmacologic treatment 1.

Considerations for Initiation

When initiating antihypertensive therapy, primary consideration should be given to comorbid conditions, such as heart failure (HF) or chronic kidney disease (CKD), for which specific classes of BP-lowering medication are indicated 1. For black patients, thiazide diuretics or CCBs may be preferred over ACE inhibitors due to their superior efficacy in preventing heart failure and stroke 1.

Titration and Combination Therapy

The American College of Cardiology and American Heart Association recommend initiating antihypertensive therapy with two agents in patients with blood pressure >20/10 mm Hg above their target, with careful monitoring to avoid hypotension or orthostatic hypotension, especially in older patients 1. However, the stepped-care approach, starting with a single agent and sequentially titrating the dose and adding other agents, is also a reasonable strategy, particularly in older adults or those at risk of hypotension or drug-associated side effects 1.

From the Research

Initiating Antihypertensive Medication

The decision to initiate antihypertensive medication should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 2.

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 2
• Drug therapy, which includes:
  • Thiazide or thiazide-like diuretics, such as hydrochlorothiazide or chlorthalidone 2, 3, 4
  • Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, such as enalapril or candesartan 2, 3, 4
  • Calcium channel blockers, such as amlodipine 2, 3, 4

Selection of Antihypertensive Medication

The selection of antihypertensive medication should be individualized, taking into account the patient's demographics, comorbidities, and other factors 5, 3, 4.

Target Blood Pressure Levels

The target blood pressure levels are:

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

Real-World Evidence

Real-world evidence suggests that there is significant variation in the initiation of antihypertensive medication, and that current guideline recommendations are not always followed 5.

Gaps in Current Guidelines

There are gaps in current guidelines, and more research is needed to provide solid evidence for the recommendations 6.