What is the initial treatment approach for a patient with hypertension?

Initial Treatment Approach for Hypertension

The initial treatment approach for hypertension should include lifestyle modifications for all patients, with pharmacologic therapy starting with a thiazide-type diuretic, ACE inhibitor, ARB, or calcium channel blocker based on patient characteristics, with combination therapy initiated for stage 2 hypertension. 1

Step 1: Lifestyle Modifications

Lifestyle modifications are the foundation of hypertension treatment for all patients with blood pressure >120/80 mmHg and should include:

• Weight loss when indicated to achieve healthy body mass index
• DASH diet (Dietary Approaches to Stop Hypertension) with:
  • Reduced sodium intake (<2,300 mg/day)
  • Increased potassium intake
  • Increased fruits and vegetables (8-10 servings/day)
  • Low-fat dairy products (2-3 servings/day)
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women
• Smoking cessation 1, 2

These lifestyle interventions can lower blood pressure by 4-11 mmHg systolic and enhance the effectiveness of antihypertensive medications 1.

Step 2: Pharmacologic Therapy Decision Algorithm

When to Start Medications:

1. Stage 1 Hypertension (BP 130-139/80-89 mmHg):

   • Start single-agent pharmacotherapy if:
     • Cardiovascular disease is present
     • Diabetes is present
     • Chronic kidney disease is present
     • 10-year cardiovascular risk ≥20%
   • Continue lifestyle modifications only if none of the above are present 1

2. Stage 2 Hypertension (BP ≥140/90 mmHg):

   • Start pharmacologic therapy for all patients 1

Initial Medication Selection:

For most patients without compelling indications, first-line options include:

1. Thiazide-type diuretics (e.g., chlorthalidone preferred over hydrochlorothiazide)
2. ACE inhibitors (e.g., lisinopril starting at 10 mg daily)
3. ARBs (e.g., losartan starting at 50 mg daily)
4. Calcium channel blockers (dihydropyridine type, e.g., amlodipine) 1, 3, 4

Special Population Considerations:

• Black patients without heart failure or CKD: Start with thiazide diuretic or calcium channel blocker 1
• Patients with diabetes or albuminuria: ACE inhibitor or ARB preferred 1
• Patients with coronary artery disease: ACE inhibitor or ARB preferred 1
• Patients with heart failure: Diuretics, ACE inhibitors (or ARBs), beta-blockers, and aldosterone receptor antagonists 1

Step 3: Monotherapy vs. Combination Therapy

• For BP 130-150/80-90 mmHg: Start with a single agent 1
• For BP ≥150/90 mmHg or >20/10 mmHg above target: Start with two-drug combination therapy 1
  • Consider fixed-dose combinations to improve adherence
  • Common effective combinations: ACE inhibitor or ARB + thiazide diuretic or calcium channel blocker

Step 4: Monitoring and Follow-up

• Assess response 2-4 weeks after initiating therapy
• Monitor serum creatinine and potassium 7-14 days after starting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Monitor for hypokalemia with diuretics
• If BP goal not achieved, increase dose or add another agent from a different class
• Target BP for most adults: <130/80 mmHg 1

Common Pitfalls to Avoid:

1. Inadequate initial dosing: Start with standard doses (e.g., lisinopril 10 mg, losartan 50 mg) rather than very low doses unless there are specific concerns 3, 4

2. Inappropriate drug selection: Avoid non-dihydropyridine calcium channel blockers (verapamil, diltiazem) in heart failure patients 1

3. Failure to adjust therapy: Approximately 50-75% of patients will require more than one medication to achieve BP control 1

4. Medication contraindications: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy and should be avoided in women of childbearing potential not using reliable contraception 1

5. Orthostatic hypotension risk: Use caution when initiating two-drug therapy in older adults; monitor BP carefully 1

By following this algorithmic approach to hypertension treatment, clinicians can effectively reduce cardiovascular morbidity and mortality in patients with hypertension.