What is the initial treatment approach for patients with hypertension?

Initial Treatment Approach for Hypertension

The initial treatment for hypertension should include lifestyle modifications for all patients, with pharmacological therapy starting with an ACE inhibitor, ARB, thiazide-like diuretic, or dihydropyridine calcium channel blocker for patients with blood pressure ≥140/90 mmHg, with consideration for combination therapy for those with BP ≥150/90 mmHg. 1

Step 1: Lifestyle Modifications

Lifestyle modifications are recommended for all patients with blood pressure >120/80 mmHg and include:

• Weight management: Achieve and maintain a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Dietary pattern: Follow a DASH or Mediterranean diet 1, 2
  • Reduce sodium intake (<2,300 mg/day)
  • Increase potassium intake (8-10 servings of fruits/vegetables per day)
  • Include low-fat dairy products (2-3 servings per day)
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week 1
• Alcohol moderation: ≤2 drinks/day for men (maximum 14/week) and ≤1 drink/day for women (maximum 9/week) 1
• Smoking cessation: Complete avoidance of tobacco products 1

Step 2: Pharmacological Therapy

When to Initiate Medications:

• Immediately for patients with:
  • BP ≥140/90 mmHg with high cardiovascular risk (established CVD, CKD, diabetes, or target organ damage) 1
  • BP ≥160/100 mmHg (regardless of risk) 1
• After 3-6 months of lifestyle intervention for patients with BP 140-159/90-99 mmHg with low-moderate cardiovascular risk 1

First-line Medication Selection:

Four classes of medications have demonstrated reduction in cardiovascular events and are recommended as first-line therapy 1:

1. ACE inhibitors (e.g., lisinopril, starting dose 10 mg daily) 3
2. ARBs (e.g., losartan, starting dose 50 mg daily) 4
3. Thiazide-like diuretics (e.g., chlorthalidone, indapamide)
4. Dihydropyridine calcium channel blockers (e.g., amlodipine)

Special Considerations for Initial Therapy:

• For non-Black patients: Start with low-dose ACE inhibitor or ARB 1
• For Black patients: Start with low-dose ARB plus dihydropyridine CCB or dihydropyridine CCB plus thiazide-like diuretic 1
• For patients with coronary artery disease or albuminuria: ACE inhibitor or ARB is preferred 1
• For patients with BP ≥150/90 mmHg: Consider initial therapy with two antihypertensive medications 1

Step 3: Monitoring and Follow-up

• Target BP: 120-129 mmHg systolic for most adults 1
• Monitoring timeline: Achieve target BP within 3 months 1, 5
• Laboratory monitoring: Check serum creatinine and potassium 7-14 days after initiation or dose change of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1

Step 4: Treatment Intensification

If BP remains uncontrolled on initial therapy:

1. Increase to full dose of initial medication
2. Add a second agent from a different class
3. Consider fixed-dose single-pill combinations to improve adherence 1

Common Pitfalls to Avoid:

1. Inadequate initial assessment: Failure to identify secondary causes of hypertension or target organ damage
2. Therapeutic inertia: Delay in intensifying treatment when BP goals are not met
3. Medication combinations to avoid: Never combine two RAS blockers (ACE inhibitor + ARB) 1
4. Pregnancy considerations: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy 1
5. Elderly considerations: Consider monotherapy with more gradual titration in elderly or frail patients 5

By following this structured approach to hypertension management, clinicians can effectively reduce cardiovascular risk and improve patient outcomes through timely intervention and appropriate medication selection.