What are the initial treatment options for managing hypertension?

Initial Treatment Options for Managing Hypertension

The first-line treatment for hypertension should include lifestyle modifications for all patients, followed by pharmacological therapy with ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics when blood pressure remains ≥140/90 mmHg despite lifestyle changes or when cardiovascular risk is elevated. 1, 2

Lifestyle Modifications (First-Line for All Patients)

Lifestyle interventions should be recommended for all patients with elevated BP or hypertension, as they can have antihypertensive effects similar to pharmacologic monotherapy:

• Physical Activity:

  • 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise weekly
  • Include dynamic or isometric resistance training 2-3 times/week 1
  • Regular exercise can reduce blood pressure by 4-9 mmHg 2

• Dietary Modifications:

  • DASH diet: increased consumption of vegetables, fruits, fish, nuts, unsaturated fatty acids
  • Low consumption of red meat and low-fat dairy products
  • Sodium restriction (<2,300 mg/day)
  • Increased potassium intake 1, 2

• Weight Management:

  • Target healthy BMI (20-25 kg/m²)
  • Target waist circumference <94 cm in men and <80 cm in women
  • Weight loss in patients with overweight/obesity can reduce BP by 5-20 mmHg 1, 2

• Alcohol Moderation:

  • Men: <14 units/week
  • Women: <8 units/week
  • Preferably avoid alcohol completely for best health outcomes 1

Pharmacological Therapy

When to Initiate Medication

Initiate antihypertensive medication when:

• BP ≥140/90 mmHg despite lifestyle modifications 1
• BP ≥160/100 mmHg (Grade 2 hypertension) immediately along with lifestyle changes 2
• BP 140-159/90-99 mmHg (Grade 1 hypertension) with target organ damage, established cardiovascular disease, diabetes, or elevated cardiovascular risk 2

First-Line Medication Options

Four main classes 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 3
   • Particularly beneficial in patients with heart failure, CKD with albuminuria, or post-MI

2. Angiotensin II receptor blockers (ARBs)

   • Alternative to ACE inhibitors when not tolerated (e.g., due to cough)
   • Beneficial in CKD with albuminuria

3. Calcium channel blockers (CCBs)

   • Particularly effective in Black patients
   • Good option for elderly patients

4. Thiazide or thiazide-like diuretics

   • Effective in most populations
   • Particularly effective in Black patients
   • Consider low-dose (e.g., hydrochlorothiazide 12.5 mg) when adding to ACE inhibitor 3

Population-Specific Considerations

• Black patients: Initial therapy should include a diuretic or CCB, either alone or with a RAS blocker 1, 2
• Elderly patients (≥65 years): Target systolic BP of 130-139 mmHg 1
• CKD patients: Target systolic BP of 120-129 mmHg if eGFR >30 mL/min/1.73m²; use RAS blockers for those with albuminuria 1, 2
• Heart failure patients: ACE inhibitors/ARBs, beta-blockers, diuretics, MRAs, and SGLT2 inhibitors for HFrEF; SGLT2 inhibitors for HFpEF 1
• Post-stroke patients: Target systolic BP of 120-130 mmHg 1, 2

Treatment Strategy and Monitoring

1. Start with a single agent at a low dose (monotherapy) or consider low-dose combination therapy
2. Reassess within 2-4 weeks to evaluate BP control and medication adherence 2
3. If BP target not achieved, increase dose or add a second agent from a different class
4. Target BP goal is <130/80 mmHg for most adults, with systolic BP 120-129 mmHg if tolerated 1, 2
5. Monitor for adverse effects: Check serum creatinine and potassium 7-14 days after initiation or dose change of ACE inhibitors, ARBs, or MRAs 2

Common Pitfalls to Avoid

• Not emphasizing lifestyle modifications: These are foundational and can reduce or eliminate the need for medications in some patients
• Inadequate follow-up: Failure to reassess within 2-4 weeks can lead to prolonged uncontrolled hypertension
• Therapeutic inertia: Reluctance to intensify treatment when BP goals are not met
• Not considering comorbidities: Treatment should be tailored based on concurrent conditions like diabetes, CKD, or heart failure
• Ignoring orthostatic hypotension: Particularly important to assess in elderly or diabetic patients 1
• Overlooking medication adherence: Consider 90-day prescription refills instead of 30-day when BP is controlled 2

By following this structured approach to hypertension management, focusing on both lifestyle modifications and appropriate pharmacological therapy, cardiovascular morbidity and mortality can be significantly reduced.