What is the first line treatment for hypertension (HTN)?

First-Line Treatment for Hypertension

The first-line treatment for hypertension includes thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers, with the specific choice depending on patient characteristics and comorbidities. 1

Initial Approach to Hypertension Treatment

Severity-Based Initial Therapy

• For BP 130/80-160/100 mmHg: Start with a single antihypertensive agent 1
• For BP ≥160/100 mmHg: Begin with two antihypertensive medications (either as separate agents or single-pill combination) 1

First-Line Medication Classes

Four major drug classes are recommended as first-line therapy:

1. Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide)
2. ACE inhibitors (e.g., lisinopril, enalapril)
3. ARBs (e.g., losartan, candesartan)
4. Dihydropyridine calcium channel blockers (e.g., amlodipine)

Patient-Specific Considerations

For Patients with Diabetes

• ACE inhibitors or ARBs are recommended first-line for patients with diabetes, especially with:
  • Albuminuria (UACR ≥30 mg/g)
  • Coronary artery disease 1
• For patients with diabetes without albuminuria, ACE inhibitors/ARBs offer no superior cardioprotection compared to thiazide diuretics or calcium channel blockers 1

For Black Patients

• Thiazide diuretics or calcium channel blockers are preferred as initial therapy 1
• ACE inhibitors are less effective in this population for BP reduction and stroke prevention

For Patients with Specific Comorbidities

• Chronic kidney disease: ACE inhibitors or ARBs 1
• Heart failure with reduced ejection fraction: ACE inhibitors/ARBs, beta-blockers 1
• Coronary artery disease: ACE inhibitors or ARBs 1

Treatment Algorithm

1. Start with lifestyle modifications for all patients:

   • Weight loss if overweight/obese
   • DASH or Mediterranean diet
   • Sodium restriction (<2,300 mg/day)
   • Increased physical activity
   • Limited alcohol consumption 1, 2

2. Initial pharmacotherapy:

   • For most patients, begin with one of the four first-line agents
   • For BP ≥160/100 mmHg, start with two agents

3. Titration and combination therapy:

   • If BP not controlled on monotherapy, add a second agent from a different class
   • Most patients will ultimately require multiple medications 1
   • Single-pill combinations improve adherence 1

Important Caveats

• Avoid combining ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 1
• Monitor kidney function and potassium in patients on ACE inhibitors, ARBs, or diuretics at least annually 1
• For resistant hypertension (uncontrolled on 3 medications including a diuretic), consider adding a mineralocorticoid receptor antagonist (spironolactone) 1
• Beta-blockers are generally not recommended as first-line therapy unless there are specific indications (e.g., heart failure, prior MI) 1
• Upfront combination therapy in a single pill may provide faster BP control and better adherence 1

Monitoring and Follow-up

• Assess BP response 4-12 weeks after initiating therapy
• Adjust therapy based on office and home BP measurements
• Target BP for most adults: <130/80 mmHg 2
• Regular monitoring of medication adherence is essential as poor adherence is a common cause of treatment failure

By following this evidence-based approach to hypertension management, clinicians can effectively reduce cardiovascular morbidity and mortality in patients with hypertension.