What is the first line treatment for hypertension?

From the Guidelines

The first line treatment for hypertension should involve lifestyle modifications, followed by medication if needed, with ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics (thiazides and thiazide-like drugs) being recommended as first-line treatments to lower blood pressure, as stated in the 2024 ESC guidelines 1.

Key Lifestyle Modifications

• Reducing sodium intake to less than 2.3g daily
• Adopting the DASH diet (rich in fruits, vegetables, and low-fat dairy)
• Regular physical activity (150 minutes of moderate exercise weekly)
• Limiting alcohol consumption
• Maintaining healthy weight
• Smoking cessation

First-Line Medications

• Thiazide diuretics (like hydrochlorothiazide 12.5-25mg daily)
• Calcium channel blockers (amlodipine 5-10mg daily)
• ACE inhibitors (lisinopril 10-40mg daily)
• Angiotensin II receptor blockers (losartan 50-100mg daily)

Patient Characteristics to Consider

• Age
• Race
• Comorbidities (e.g. diabetes, heart failure)
• The 2024 ESC guidelines recommend combining two drugs from different classes as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg) 1.
• The choice of medication should be individualized based on patient characteristics, with ACE inhibitors preferred in patients with diabetes or heart failure, and calcium channel blockers working better in Black patients, as noted in the 2018 ACC/AHA guideline 1.
• Regular blood pressure monitoring is essential to assess treatment effectiveness, as emphasized in the 2018 ACC/AHA guideline 1 and the 2024 ESC guidelines 1.

From the FDA Drug Label

Lisinopril tablets, USP, are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. The first line treatment for high blood pressure or hypertension is not explicitly stated in the provided drug labels. However, lisinopril is indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure 2. It is also mentioned that many patients will require more than one drug to achieve blood pressure goals, and for specific advice on goals and management, one should 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) 2. Lisinopril may be administered alone or with other antihypertensive agents 2. The choice of therapy should be guided by considerations such as the patient's race, age, and comorbidities (e.g. diabetes or hyperlipidemia), as well as the presence of other indications for specific antihypertensive drugs (e.g. angina, heart failure, or diabetic kidney disease) 2.

From the Research

First Line Treatment for Hypertension

The first line treatment for hypertension typically involves lifestyle modifications and pharmacological interventions.

• Lifestyle modifications include weight loss, a healthy dietary pattern with low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption 3.
• Pharmacological interventions usually involve the use of thiazide or thiazide-like diuretics, such as hydrochlorothiazide or chlorthalidone, as the initial treatment option 4, 5, 6, 3.

Thiazide Diuretics

Thiazide diuretics are commonly prescribed for the treatment of hypertension due to their effectiveness in reducing blood pressure and cardiovascular risk.

• Chlorthalidone is considered a preferred thiazide diuretic for the treatment of primary hypertension due to its long half-life and large volume of distribution 5, 7, 6.
• Hydrochlorothiazide is also widely used, although it may not be as effective as chlorthalidone in reducing systolic blood pressure 7.

Other Treatment Options

Other treatment options for hypertension include:

• Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, such as enalapril or candesartan 3.
• Calcium channel blockers, such as amlodipine 3.
• Loop diuretics, which may be useful in alternative circumstances, such as in patients with chronic kidney disease or significant fluid overload 5, 6.

Treatment Goals

The goal of treatment for hypertension is to achieve a blood pressure target of less than 130/80 mmHg for adults under 65 years and a systolic blood pressure target of less than 130 mmHg for adults 65 years and older 3.

• Treatment should be titrated according to office and home blood pressure levels to achieve these targets 3.