What is the first line treatment for hypertension?

First-Line Treatment for Hypertension

The first-line treatment for hypertension should include one of the four major drug classes: ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, or thiazide/thiazide-like diuretics, preferably as a low-dose combination therapy for most patients with confirmed hypertension. 1, 2

Initial Treatment Approach

For Newly Diagnosed Hypertension:

• Blood pressure 140-159/90-99 mmHg:

  • Start with a single-pill combination of two first-line agents at low doses 1, 2
  • Alternatively, monotherapy may be considered for those with elevated BP (not yet hypertensive) 1

• Blood pressure ≥160/100 mmHg:

  • Immediate initiation of two-drug combination therapy is strongly recommended 1, 2

First-Line Drug Classes:

1. ACE inhibitors (e.g., enalapril, lisinopril)
2. ARBs (e.g., losartan, candesartan)
3. Dihydropyridine calcium channel blockers (e.g., amlodipine)
4. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)

Special Considerations for Drug Selection

• Patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g): Initial treatment should include an ACE inhibitor or ARB to reduce risk of progressive kidney disease 1, 2

• Patients with diabetes and established coronary artery disease: ACE inhibitors or ARBs are recommended as first-line therapy 1, 2

• Race considerations: The BP-lowering effect may be less pronounced in Black patients with certain medications, particularly ACE inhibitors and ARBs when used as monotherapy 3, 4

Important Combinations to Avoid

• Do not combine ACE inhibitors with ARBs 1, 2
• Do not combine ACE inhibitors or ARBs with direct renin inhibitors 1

Lifestyle Modifications

Lifestyle modifications should be implemented concurrently with pharmacotherapy:

• Weight reduction if overweight/obese
• DASH dietary pattern (rich in fruits, vegetables, low-fat dairy)
• Sodium restriction (<2,300 mg/day)
• Increased physical activity
• Moderation of alcohol consumption 1, 2, 4

Treatment Escalation

If blood pressure remains uncontrolled:

1. Optimize the initial two-drug combination to maximum tolerated doses
2. Progress to a three-drug combination: RAS blocker + CCB + thiazide/thiazide-like diuretic
3. For resistant hypertension (uncontrolled on triple therapy), add spironolactone as fourth-line agent 1, 2

Monitoring and Follow-up

• Follow up within 2-4 weeks after starting or changing medications
• Monitor serum creatinine and potassium within 7-14 days after initiating ACE inhibitors or ARBs 2
• Annual monitoring of renal function and electrolytes for patients on ACE inhibitors, ARBs, or diuretics 1

Target Blood Pressure

• For most adults: <130/80 mmHg 2
• Systolic BP target of 120-129 mmHg if tolerated 2

The evidence strongly supports that early and effective blood pressure control significantly reduces cardiovascular morbidity and mortality, with combination therapy often providing more rapid and effective control than monotherapy alone 1, 4.