Initial Treatment Options for Managing Hypertension
For most patients with hypertension, thiazide-type diuretics should be used as initial therapy, either alone or in combination with one of the other classes (ACEIs, ARBs, BBs, CCBs) that have also been shown to reduce hypertensive complications. 1
First-Line Medication Selection
Based on Patient Demographics:
For non-Black patients:
- Recommended initial therapy: ACE inhibitor/ARB
- Alternative options: Dihydropyridine calcium channel blockers or thiazide-like diuretics 2
For Black patients:
- Preferred initial therapy: ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic
- Rationale: ACE inhibitors are less effective than thiazide diuretics and CCBs in lowering BP and preventing stroke in this population 2
For patients with diabetes and hypertension:
- Recommended: ACE inhibitor or ARB, particularly with albuminuria 2
For patients with albuminuria (UACR ≥30 mg/g):
- Initial treatment should include an ACE inhibitor or ARB to reduce risk of progressive kidney disease 2
Severity-Based Approach:
Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mmHg):
- Thiazide-type diuretics for most patients 1
Stage 2 Hypertension (SBP ≥160 or DBP ≥100 mmHg):
Specific Medication Dosing
Lisinopril (ACE inhibitor):
- Initial dose: 10 mg once daily
- Usual dosage range: 20-40 mg per day in a single daily dose
- When used with diuretics: Start at 5 mg once per day 3
Thiazide diuretics:
- Available in fixed-dose combinations with other agents
- Examples: Hydrochlorothiazide (12.5-50 mg) 1
Combination Therapy Approach
The European Society of Cardiology recommends a stepwise approach 2:
- Initial therapy: RAS blocker (ACE inhibitor/ARB) + either dihydropyridine CCB or thiazide/thiazide-like diuretic
- If BP not controlled: Progress to three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic
- If still not controlled: Add spironolactone as fourth-line agent
Essential Lifestyle Modifications
Lifestyle modifications should be implemented alongside pharmacotherapy 2, 4:
Dietary changes:
- DASH diet (increased consumption of vegetables, fruits, low-fat dairy products)
- Sodium restriction (<2,300 mg/day)
- Increased potassium intake
Physical activity:
- 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise weekly
- Dynamic or isometric resistance training 2-3 times/week
Weight management:
- Target healthy BMI (20-25 kg/m²)
- Waist circumference <94 cm in men and <80 cm in women
Alcohol moderation:
- Men: <14 units/week
- Women: <8 units/week
Smoking cessation
Target Blood Pressure Goals
- For most adults: <130/80 mmHg with systolic blood pressure 120-129 mmHg if tolerated 2
- For adults aged 65+ years: <150 mmHg systolic 2
Follow-Up and Monitoring
- Schedule follow-up within 2-4 weeks to assess blood pressure control and medication adherence 2
- Monitor for adverse effects:
- Check serum creatinine and potassium 7-14 days after initiation or dose change of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2
- Watch for orthostatic hypotension, especially in elderly patients
Common Pitfalls to Avoid
- Don't delay combination therapy in patients with BP significantly above target (>20/10 mmHg above goal) 2
- Don't use beta-blockers as first-line unless there are specific indications (angina, post-MI, heart failure) 2
- Don't combine ACE inhibitors with ARBs as this increases adverse effects without additional benefit 2
- Don't neglect medication adherence - fixed-dose combinations improve adherence and outcomes 2
- Don't overlook hypokalemia with thiazide diuretics - positive benefits of diuretic therapy may not be apparent when serum potassium levels are below 3.5 mmol/L 1