What is the initial management of hypertension (HTN)?

Initial Management of Hypertension (HTN)

The initial management of hypertension should include lifestyle modifications for all patients, with pharmacotherapy initiated using a single agent from one of four first-line drug classes: ACE inhibitors, ARBs, thiazide/thiazide-like diuretics, or dihydropyridine calcium channel blockers, based on patient-specific factors. 1

Lifestyle Modifications

Lifestyle modifications are the foundation of hypertension management and should be recommended to all patients:

• Weight management: Achieve and maintain healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Physical activity: 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise weekly, plus resistance training 2-3 times/week 1
• Dietary modifications:
  • DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy)
  • Sodium restriction (<2,300 mg/day)
  • Increased potassium intake 1, 2
• Alcohol moderation: Men <14 units/week, women <8 units/week 1
• Smoking cessation 1

Pharmacological Management

First-Line Medication Options

Four main drug classes are recommended as first-line therapy for hypertension:

1. ACE inhibitors (e.g., lisinopril, starting dose 10 mg daily) 3
2. ARBs (e.g., losartan, starting dose 50 mg daily) 4
3. Thiazide/thiazide-like diuretics (e.g., hydrochlorothiazide, starting dose 12.5-25 mg daily) 5
4. Dihydropyridine calcium channel blockers (e.g., amlodipine) 1

Patient-Specific Considerations for Medication Selection

• Patients with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB is recommended first-line 6, 1
• Patients with diabetes: ACE inhibitor or ARB preferred, particularly with albuminuria 6, 1
• Black patients: Preferred initial therapy is either:
  • ARB + dihydropyridine CCB, or
  • Dihydropyridine CCB + thiazide-like diuretic 1
• Patients with established coronary artery disease: ACE inhibitor or ARB recommended first-line 6
• Patients with significantly elevated BP (>20/10 mmHg above goal): Consider initiating with two-drug combination therapy 1

Dosing and Titration

• Start with recommended initial dose and titrate based on BP response
• For lisinopril: Start with 10 mg daily, usual range 20-40 mg daily 3
• For losartan: Start with 50 mg daily, can increase to 100 mg daily 4
• For hydrochlorothiazide: Start with 12.5-25 mg daily 5
• Reassess BP in 2-4 weeks after initiation or dose adjustment 1

Monitoring

• Monitor serum creatinine/eGFR and potassium within 7-14 days after initiation of ACE inhibitors, ARBs, or diuretics, and at least annually thereafter 6, 1
• Assess for adverse effects, including orthostatic hypotension, electrolyte imbalances, and renal function changes 1
• Consider home BP monitoring or ambulatory BP monitoring to exclude white-coat hypertension and establish BP patterns outside clinical settings 1

Treatment Algorithm

1. Confirm hypertension diagnosis: BP ≥140/90 mmHg
2. Initiate lifestyle modifications for all patients
3. Assess for specific indications that would favor one medication class:
   • Albuminuria → ACE inhibitor/ARB
   • Diabetes → ACE inhibitor/ARB
   • Coronary artery disease → ACE inhibitor/ARB
   • Black race → CCB or thiazide diuretic
4. Initiate appropriate first-line agent based on patient characteristics
5. If BP significantly above target (>20/10 mmHg above goal), consider initial combination therapy
6. Monitor and titrate medication dose based on BP response
7. If BP not controlled on monotherapy, add a second agent from a different class
8. If BP still not controlled, use three-drug combination: RAS blocker + CCB + thiazide diuretic
9. If BP remains uncontrolled, add spironolactone as fourth-line agent 1

Important Cautions

• Do not combine ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury without additional benefit 6, 1
• Beta-blockers are not recommended as first-line unless specific indications exist (prior MI, active angina, heart failure) 1
• Fixed-dose combinations may improve medication adherence 1
• Monitor closely for adverse effects, particularly in elderly patients or those with comorbidities 1

By following this structured approach to hypertension management, clinicians can effectively control blood pressure and reduce cardiovascular risk in most patients.