What are the first-line medications for managing hypertension?

First-Line Medications for Hypertension Management

First-line medications for hypertension include thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers (CCBs), with selection based on patient characteristics such as race and comorbidities. 1, 2

Initial Medication Selection

Based on Race:

Non-Black Patients:

• First choice: Low-dose ACE inhibitor or ARB 2
• Increase to full dose if needed
• Add thiazide/thiazide-like diuretic if BP remains uncontrolled

Black Patients:

• First choice: Low-dose ARB or dihydropyridine CCB (DHP-CCB) or combination with thiazide/thiazide-like diuretic 2
• Increase to full dose if needed
• Add diuretic or ACE inhibitor/ARB if BP remains uncontrolled

Based on Hypertension Severity:

• Stage 1 hypertension: Single agent with dose titration and sequential addition of other agents 2
• Stage 2 hypertension (BP >20/10 mmHg above target): Initial combination therapy with two agents from different classes 2, 1

Preferred Agents and Evidence

Thiazide diuretics, particularly chlorthalidone, have demonstrated superiority in preventing heart failure compared to amlodipine (CCB) and lisinopril (ACE inhibitor) 2. Chlorthalidone is preferred over hydrochlorothiazide due to its longer half-life and better cardiovascular outcomes 1.

For combination therapy, the AB/CD rule is recommended:

• A: ACE inhibitor or ARB
• B: Beta-blocker
• C: Calcium channel blocker
• D: Diuretic 1

Special Considerations

• Patients with albuminuria or CKD: ACE inhibitor or ARB as first-line 1
• Women of childbearing potential: Avoid ACE inhibitors and ARBs due to teratogenic potential 1
• Elderly patients (>80 years) or frail: Simplify regimen with once-daily dosing and single-pill combinations 2

Important Caveats

1. Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury without added benefit 1

2. Monitor closely:

   • Blood pressure (target achievement within 3 months)
   • Renal function and electrolytes, especially with ACE inhibitors, ARBs, or diuretics 1

3. Beta-blockers are less effective than CCBs and thiazide diuretics for reducing cardiovascular events in the general population and are not recommended as first-line therapy unless specific indications exist 2

4. Alpha-blockers are not recommended as first-line therapy due to less effectiveness for cardiovascular disease prevention 2

5. For Black patients, ACE inhibitors are less effective than CCBs in preventing heart failure and stroke 2

Treatment Targets

• Target BP for most adults: <130/80 mmHg 1
• For elderly patients: Individualize based on frailty, with minimum acceptable level of <150/90 mmHg 1
• Aim to reduce BP by at least 20/10 mmHg 2

Remember that lifestyle modifications (DASH diet, sodium restriction, physical activity, weight reduction, and limited alcohol consumption) should accompany pharmacological therapy to enhance effectiveness 1, 3.