What is the initial approach for managing hypertension with medications, including Angiotensin-Converting Enzyme (ACE) inhibitors, Angiotensin II Receptor Blockers (ARBs), Calcium Channel Blockers (CCBs), and thiazide Diuretics?

Initial Approach to Hypertension Medication Management

For patients with confirmed hypertension, initial medication therapy should include a thiazide-like diuretic, ACE inhibitor, ARB, or calcium channel blocker, with specific choices based on patient characteristics and comorbidities. 1

Initial Assessment of Blood Pressure Severity

The approach to medication therapy depends on the severity of hypertension:

• BP 140/90 - 159/99 mmHg: Start with a single antihypertensive agent 1
• BP ≥160/100 mmHg: Initiate with two antihypertensive medications simultaneously (either as separate agents or fixed-dose combination) 1

First-Line Medication Selection Algorithm

Step 1: Evaluate for Specific Indications

1. For Black patients:

   • First choice: Thiazide-like diuretic or calcium channel blocker 1

2. For patients with albuminuria (UACR ≥30 mg/g):

   • First choice: ACE inhibitor or ARB 1
   • Maximum tolerated dose is recommended 1

3. For patients with diabetes and coronary artery disease:

   • First choice: ACE inhibitor or ARB 1

4. For patients without specific indications:

   • Any of the four major classes can be used (thiazide diuretic, ACE inhibitor, ARB, or CCB) 1

Step 2: Dosing Strategy

• Start with standard doses (e.g., lisinopril 10 mg daily for ACE inhibitors) 2
• Titrate dose upward if blood pressure goal is not achieved within 2-4 weeks 1
• Monitor serum creatinine, eGFR, and potassium levels at least annually for patients on ACE inhibitors, ARBs, or diuretics 1

Combination Therapy Approach

When monotherapy is insufficient:

Two-Drug Combinations (Preferred Options)

• Thiazide diuretic + ACE inhibitor or ARB
• Calcium channel blocker + ACE inhibitor or ARB
• Calcium channel blocker + thiazide diuretic 1, 3

Important caution: Never combine an ACE inhibitor with an ARB due to increased risk of adverse effects without additional cardiovascular benefit 1

Three-Drug Combinations

For resistant hypertension (BP not controlled on three drugs including a diuretic):

• Preferred combination: CCB + thiazide diuretic + ACE inhibitor or ARB 1
• Consider adding a mineralocorticoid receptor antagonist as fourth-line therapy 1

Medication-Specific Considerations

Thiazide Diuretics

• Long-acting agents like chlorthalidone and indapamide are preferred 1, 4
• Monitor for hyperglycemia, hyperuricemia, and electrolyte disturbances 1, 5

ACE Inhibitors

• Monitor for cough, angioedema, hyperkalemia
• Contraindicated in pregnancy 1, 2
• May provide additional benefit in patients with proteinuria or heart failure 1

ARBs

• Similar efficacy to ACE inhibitors with better tolerability profile 3
• Contraindicated in pregnancy 1
• Alternative when ACE inhibitor cough develops 1

Calcium Channel Blockers

• Dihydropyridine CCBs (e.g., amlodipine) are preferred for hypertension 1
• Monitor for peripheral edema 5

Common Pitfalls to Avoid

1. Inappropriate combination therapy: Avoid combining ACE inhibitors with ARBs 1

2. Inadequate monitoring: Always monitor renal function and electrolytes in patients on ACE inhibitors, ARBs, or diuretics 1

3. Delayed intensification: Don't wait too long to add a second agent if BP remains uncontrolled 1

4. Overlooking secondary causes: Before diagnosing resistant hypertension, exclude medication nonadherence, white coat hypertension, and secondary hypertension 1

5. Discontinuing effective therapy: If BP is below target without adverse effects, continue the current regimen rather than reducing doses 1

By following this algorithm, clinicians can systematically approach hypertension management with evidence-based medication choices that optimize cardiovascular outcomes and minimize adverse effects.