What is the recommended pharmacological management for newly diagnosed hypertension?

Pharmacological Management of Newly Diagnosed Hypertension

For most patients with newly diagnosed hypertension (BP ≥140/90 mmHg), initial treatment should be combination therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker (CCB) or thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1

Initial Assessment and Treatment Decision

Blood Pressure Thresholds for Treatment:

• BP ≥140/90 mmHg: Initiate pharmacological treatment immediately 1
• BP 130-139/80-89 mmHg:
  • With existing cardiovascular disease: Initiate pharmacological treatment 1
  • With high cardiovascular risk, diabetes, or chronic kidney disease: Consider pharmacological treatment 1
  • Without high risk: Lifestyle modifications for 3 months before considering medication 1

First-Line Medication Options:

1. Thiazide/thiazide-like diuretics (e.g., chlorthalidone, indapamide)
2. ACE inhibitors (e.g., lisinopril)
3. Angiotensin receptor blockers (ARBs) (e.g., losartan)
4. Long-acting dihydropyridine calcium channel blockers (CCBs) (e.g., amlodipine)

All four classes have demonstrated effective BP reduction and cardiovascular event prevention 1.

Treatment Algorithm

Step 1: Initial Treatment Strategy

• For most patients with BP ≥140/90 mmHg: Start with combination therapy of two drugs 1

  • Preferred combinations: RAS blocker (ACE inhibitor or ARB) + CCB or thiazide/thiazide-like diuretic
  • Use single-pill combinations when available to improve adherence 1, 2

• Special considerations for initial therapy:

  • Patients ≥85 years, with symptomatic orthostatic hypotension, or with moderate-to-severe frailty: Consider starting with monotherapy 1
  • Black patients: Preferred combination is ARB + dihydropyridine CCB or thiazide/thiazide-like diuretic 2
  • Patients with BP ≥20/10 mmHg above target: Consider starting with triple therapy 1

Step 2: If BP Not Controlled

• Increase to triple therapy: RAS blocker + CCB + thiazide/thiazide-like diuretic 1, 2
• Use single-pill combinations when possible 1

Step 3: Resistant Hypertension Management

• Add low-dose spironolactone (12.5-25 mg daily) 1, 2
• If spironolactone is not tolerated, consider:
  • Eplerenone
  • Higher dose of thiazide/thiazide-like diuretic
  • Loop diuretic (if eGFR <30 ml/min/1.73m²)
  • Beta-blocker (e.g., bisoprolol)
  • Alpha-blocker (e.g., doxazosin) 1

Treatment Targets

• General target for most adults: <130/80 mmHg 2
• Patients without comorbidities: <140/90 mmHg 1
• Patients with known cardiovascular disease: <130 mmHg systolic 1, 2
• High-risk patients (with high CVD risk, diabetes, CKD): <130 mmHg systolic 1

Important Considerations and Caveats

• Avoid combining two RAS blockers (ACE inhibitor + ARB) as this increases adverse effects without additional benefit 1, 2
• Beta-blockers are not recommended as first-line therapy unless there are specific indications (e.g., angina, post-MI, heart failure) 1
• Medication timing: Take medications at the most convenient time of day to establish a habitual pattern and improve adherence 1
• Follow-up: Monitor monthly after initiation until target BP is reached, then every 3-6 months 1, 2
• Chlorthalidone may be preferred over hydrochlorothiazide due to longer duration of action and potentially better cardiovascular outcomes 3
• Low-dose thiazides (12.5-25 mg hydrochlorothiazide or equivalent) provide most of the BP-lowering benefit with fewer metabolic side effects 4, 5

Special Populations

• Young adults (<40 years): Consider screening for secondary causes of hypertension 1
• Black patients: CCBs and thiazide diuretics may be more effective than ACE inhibitors as monotherapy 1
• Elderly patients (≥65 years): Blood pressure targets should be individualized based on frailty and tolerability 2
• Pregnancy: Different medication choices apply (methyldopa, labetalol, nifedipine) 1

The pharmacological management of hypertension has evolved toward earlier use of combination therapy to achieve better and faster BP control. Single-pill combinations improve adherence and outcomes compared to multiple separate pills, making them the preferred approach for most patients with newly diagnosed hypertension.