What is the initial treatment approach for hypertension?

Initial Treatment Approach for Hypertension

The initial treatment for hypertension should include lifestyle modifications, with pharmacologic therapy added for blood pressure ≥140/90 mmHg, preferably using an ACE inhibitor, ARB, thiazide-like diuretic, or dihydropyridine calcium channel blocker as first-line agents. 1, 2

Lifestyle Modifications (First-Line for All Patients)

Lifestyle modifications should be implemented for all patients with blood pressure >120/80 mmHg and include:

• Weight loss if overweight or obese
• DASH diet (Dietary Approaches to Stop Hypertension)
• Sodium restriction (<2,300 mg/day)
• Increased potassium intake (fruits and vegetables)
• Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women)
• Regular physical activity (at least 150 min of moderate-intensity activity per week)
• Smoking cessation 1, 2

These lifestyle interventions can lower blood pressure, enhance the effectiveness of antihypertensive medications, and promote overall metabolic and vascular health 1.

Pharmacologic Therapy

When to Initiate Medication

• BP 130/80-150/90 mmHg: Start with a single antihypertensive agent plus lifestyle modifications 1
• BP ≥150/90 mmHg: Initial treatment with two antihypertensive medications is recommended 1, 2

First-Line Medication Options

Four major drug classes have demonstrated reduction in cardiovascular events and are recommended as first-line therapy:

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

Special Considerations for Medication Selection

• Patients with albuminuria (UACR ≥30 mg/g): Initial treatment should include an ACE inhibitor or ARB 1
• Patients with established coronary artery disease: ACE inhibitors or ARBs are recommended first-line 1
• Patients with chronic kidney disease: ACE inhibitors or ARBs are preferred 1

Medication Dosing and Monitoring

• Start with standard doses (e.g., lisinopril 10 mg daily) 3
• Monitor blood pressure response and adjust dosage accordingly
• For patients on ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists:
  • Check serum creatinine and potassium 7-14 days after initiation or dose change 1, 2
• For patients on diuretics:
  • Monitor for hypokalemia 1

Treatment Algorithm

1. BP >120/80 mmHg but <140/90 mmHg: Implement lifestyle modifications only
2. BP 140/90-150/90 mmHg: Start single agent + lifestyle modifications
   • Choose from ACE inhibitor, ARB, thiazide-like diuretic, or calcium channel blocker
   • For patients with albuminuria or CAD: Start with ACE inhibitor or ARB
3. BP ≥150/90 mmHg: Start two-drug combination + lifestyle modifications
   • Preferred combination: ACE inhibitor or ARB plus either thiazide-like diuretic or calcium channel blocker
4. Inadequate response: Add third agent from remaining first-line classes

Common Pitfalls to Avoid

• Failure to implement lifestyle modifications: These are essential components of hypertension management, not optional add-ons 1
• Combining ACE inhibitors with ARBs: This combination should be avoided due to increased risk of adverse effects without additional benefit 1, 2
• Inadequate monitoring: Failure to check renal function and electrolytes after starting RAS blockers 1
• Medication in pregnancy: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy 1
• Insufficient follow-up: Patients should be monitored regularly to assess treatment response and adjust therapy as needed 2

Target Blood Pressure Goals

The general target blood pressure is <130/80 mmHg for most patients, though this may be individualized based on comorbidities and age 1, 2.