What is the initial treatment approach for primary hypertension?

Initial Treatment Approach for Primary Hypertension

The initial treatment approach for primary hypertension should include lifestyle modifications for all patients, with immediate pharmacological therapy initiated for Grade 2 hypertension (≥160/100 mmHg) or Grade 1 hypertension (140-159/90-99 mmHg) with high cardiovascular risk, target organ damage, diabetes, or CKD. 1

Diagnosis and Assessment

• Hypertension is diagnosed when blood pressure is persistently elevated, with diagnosis confirmed through:

  • Office BP measurements (at least 2 readings, averaged)
  • Home BP monitoring
  • 24-hour ambulatory BP monitoring 1

• Classification of hypertension:

  • Normal BP: <130/85 mmHg
  • Elevated BP: 130-139/85-89 mmHg
  • Grade 1 hypertension: 140-159/90-99 mmHg
  • Grade 2 hypertension: ≥160/100 mmHg 1

Lifestyle Modifications

Lifestyle modifications are recommended for all patients with elevated blood pressure or hypertension:

1. Dietary modifications:

   • DASH diet (rich in fruits, vegetables, low-fat dairy)
   • Sodium restriction (<2,300 mg/day)
   • Increased potassium intake
   • Moderate alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) 1

2. Physical activity:

   • At least 30 minutes of moderate-intensity aerobic exercise 5-7 days/week (can reduce BP by 4-9 mmHg) 1

3. Weight management:

   • Target BMI <25 kg/m²
   • Weight loss in overweight/obese patients can reduce BP by 5-20 mmHg 1

4. Other recommendations:

   • Smoking cessation
   • Stress management techniques 1

These lifestyle interventions have been shown to have antihypertensive effects similar to pharmacologic monotherapy 2 and can be effective in preventing or controlling stage 1 hypertension 3.

Pharmacological Therapy

When to Initiate Medication

• Immediate initiation of pharmacological therapy for:

  • Grade 2 hypertension (≥160/100 mmHg)
  • Grade 1 hypertension (140-159/90-99 mmHg) with high CV risk, target organ damage, diabetes, CKD, or age 50-80 years 1

• After 3-6 months of lifestyle modifications for patients with persistent Grade 1 hypertension without the above risk factors 1

First-Line Medication Options

Four main classes of medications are recommended as first-line therapy:

1. ACE inhibitors (e.g., lisinopril)

   • Initial dose: 10 mg once daily
   • Usual dosage range: 20-40 mg per day 4

2. Angiotensin II receptor blockers (ARBs) (e.g., losartan)

3. Dihydropyridine calcium channel blockers

4. Thiazide or thiazide-like diuretics 1

Population-Specific Recommendations

• For non-Black patients:

  • Initial therapy: low-dose ACE inhibitor/ARB
  • Alternatives: dihydropyridine calcium channel blockers or thiazide-like diuretics 1

• For Black patients:

  • Initial therapy: low-dose ARB + dihydropyridine calcium channel blocker or a dihydropyridine calcium channel blocker + thiazide-like diuretic 1

• For patients with diabetes:

  • Target BP: <130/80 mmHg 2
  • ACE inhibitors or ARBs are preferred first-line agents due to potential advantages in reducing cardiovascular events 2, 1

Treatment Goals and Monitoring

• Target blood pressure:

  • General target: <140/90 mmHg for most adults 1
  • For patients with diabetes: <130/80 mmHg 2
  • For elderly patients (≥65 years): <150 mmHg systolic 1

• Monitoring:

  • Monthly visits until blood pressure targets are achieved
  • Reassessment within 2-4 weeks to evaluate BP control, medication adherence, and response to treatment
  • Laboratory monitoring (serum creatinine and potassium) 7-14 days after initiation or dose change of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1

Combination Therapy

If blood pressure is not controlled with monotherapy:

• Add a second agent from a different class
• Consider low-dose combination therapy, which may be more effective with fewer side effects than higher doses of a single agent
• Most hypertensive patients will require two or more drugs for blood pressure control 5

Common Pitfalls and Caveats

1. Inadequate lifestyle modifications: Many patients focus solely on medications and neglect the significant impact of lifestyle changes.

2. White-coat hypertension: Consider ambulatory or home BP monitoring to confirm the diagnosis before initiating therapy.

3. Medication non-adherence: Use 90-day prescription refills instead of 30-day when BP is controlled, and consider telehealth strategies to improve adherence 1.

4. Inappropriate diuretic selection: Consider switching to loop diuretics if eGFR <30 ml/min/1.73m² or clinical volume overload 1.

5. Overlooking secondary causes: Consider screening for secondary causes in patients with resistant hypertension or early-onset hypertension.