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

Lifestyle Modifications

Before or alongside pharmacological therapy:

• Weight loss if overweight/obese
• DASH or Mediterranean dietary pattern
• Sodium restriction (<2,300 mg/day)
• Increased physical activity
• Limited alcohol consumption (≤2 drinks/day for men, ≤1 for women)
• Increased potassium intake

Pharmacological Therapy Decision Algorithm

Step 1: Assess Blood Pressure Severity

• BP 130/80-159/99 mmHg: Consider starting with a single agent
• BP ≥160/100 mmHg: Start with two-drug combination therapy 1

Step 2: Consider Patient-Specific Factors

For patients with diabetes:

• ACE inhibitor or ARB is preferred first-line, especially with:
  • Albuminuria (UACR ≥30 mg/g)
  • Coronary artery disease 1

For patients with chronic kidney disease:

• ACE inhibitor or ARB is preferred first-line 1

For Black patients without CKD or heart failure:

• Thiazide-like diuretic or calcium channel blocker is preferred first-line 1

For general population without specific indications:

• Any of the four major classes can be used: thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers 1

Medication Classes and Considerations

Thiazide and Thiazide-like Diuretics

• Long-acting agents like chlorthalidone and indapamide are preferred over hydrochlorothiazide 1
• Particularly effective in Black patients and older adults
• Monitor for electrolyte abnormalities, especially hypokalemia

ACE Inhibitors/ARBs

• Particularly beneficial in patients with:
  • Diabetes
  • Chronic kidney disease
  • Heart failure
  • Coronary artery disease
• Monitor renal function and potassium levels annually 1
• ARBs may be better tolerated than ACE inhibitors in Black patients (less cough and angioedema)

Calcium Channel Blockers (Dihydropyridine)

• Effective in all demographic groups
• Particularly effective in Black patients
• Common side effects include peripheral edema and headache

Beta Blockers

• Not recommended as first-line therapy unless there are specific indications:
  • Prior myocardial infarction
  • Active angina
  • Heart failure with reduced ejection fraction 1
• Less effective for stroke prevention, especially in older adults 1

Combination Therapy Considerations

• Most patients will require multiple medications to achieve BP targets
• Single-pill combinations improve adherence 1
• Avoid combining ACE inhibitors with ARBs 1
• For resistant hypertension (uncontrolled on 3 drugs including a diuretic), consider adding a mineralocorticoid receptor antagonist 1

Common Pitfalls and Caveats

1. Inadequate dosing: Ensure timely titration to achieve BP goals
2. Inappropriate combinations: Avoid ACE inhibitor + ARB combinations
3. Neglecting to monitor: Check renal function and electrolytes at least annually in patients on ACE inhibitors, ARBs, or diuretics 1
4. Overlooking adherence issues: Address medication cost, side effects, and dosing complexity
5. Ignoring secondary causes: Consider screening for secondary hypertension in resistant cases
6. Relying solely on office BP measurements: Consider home or ambulatory BP monitoring for diagnosis and treatment assessment

By following this algorithm and selecting appropriate first-line therapy based on patient characteristics, you can effectively manage hypertension and reduce cardiovascular morbidity and mortality.