What is the first line treatment for hypertension?

First-Line Treatment for Hypertension

The first-line treatment for hypertension includes thiazide-like diuretics, ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers, with the choice depending on patient characteristics and comorbidities. 1, 2

Initial Treatment Algorithm

Step 1: Lifestyle Modifications (for all patients)

• Weight reduction if overweight/obese
• DASH-style eating pattern
• Sodium restriction (<2,300 mg/day)
• Increased potassium intake through fruits and vegetables
• Physical activity (150+ minutes/week)
• Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) 1

Step 2: Pharmacologic Therapy Based on Patient Profile

For General Population:

• Any of these first-line agents can be used:
  • Thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide)
  • ACE inhibitors
  • ARBs
  • Dihydropyridine calcium channel blockers 1, 2

For Specific Populations:

• Patients with diabetes or albuminuria (UACR ≥30 mg/g): Start with ACE inhibitor or ARB 1, 3
• Patients with established coronary artery disease: Start with ACE inhibitor or ARB 1
• African American patients: Consider thiazide diuretic or calcium channel blocker 1

Blood Pressure Thresholds and Treatment Intensity

• BP 140-159/90-99 mmHg: Start with single agent 1
• BP ≥160/100 mmHg: Start with two-drug combination 1

Monitoring and Dose Adjustment

• Check serum creatinine, eGFR, and potassium within 7-14 days after initiating ACE inhibitors, ARBs, or diuretics 1
• Monitor annually thereafter 1
• Titrate medication dose before adding additional agents 3

Evidence Supporting First-Line Choices

Thiazide diuretics have the strongest evidence for reducing mortality and cardiovascular events in hypertension. Chlorthalidone specifically has demonstrated superiority in preventing stroke compared to lisinopril and in preventing heart failure compared to amlodipine 4. Multiple systematic reviews have confirmed that thiazide diuretics are at least as effective as other antihypertensive classes in reducing mortality and stroke incidence 4.

ACE inhibitors have also demonstrated mortality reduction compared to placebo and are particularly beneficial in patients with diabetes, albuminuria, or cardiovascular disease 1, 5.

Common Pitfalls to Avoid

1. Inappropriate combinations: Never combine ACE inhibitors with ARBs or with direct renin inhibitors due to increased risk of hyperkalemia, syncope, and acute kidney injury without added benefit 1

2. Inadequate monitoring: Failure to check renal function and electrolytes after initiating ACE inhibitors, ARBs, or diuretics can miss early adverse effects 1

3. Therapeutic inertia: Delaying medication titration or addition when BP remains uncontrolled 1

4. Ignoring secondary causes: Consider secondary hypertension in patients with resistant hypertension, early-onset hypertension (<30 years), or abrupt BP changes 1

5. Overlooking metabolic effects: While thiazides can cause minor metabolic effects (hyperglycemia), these don't negate their cardiovascular benefits 4

The most recent evidence supports using any of the four first-line agents (thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers), with the specific choice guided by patient characteristics, comorbidities, and tolerance. The focus should be on achieving blood pressure control rather than the specific agent used to achieve it, as blood pressure reduction itself is what drives cardiovascular risk reduction 1, 2.