First-Line Management of Hypertension
Lifestyle modification is the first line of antihypertensive treatment for all patients with hypertension, followed by pharmacological therapy when blood pressure remains ≥140/90 mmHg despite lifestyle changes. 1, 2
Lifestyle Modifications
Lifestyle modifications are essential and should include:
- Salt reduction: Limit to approximately 2g sodium per day (equivalent to 5g salt)
- Healthy diet: Follow DASH or Mediterranean diet rich in fruits, vegetables, whole grains, and low-fat dairy products
- Weight management: Target healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women)
- Physical activity: At least 150 minutes/week of moderate-intensity aerobic exercise (30 min, 5-7 days/week) plus resistance training 2-3 times/week
- Alcohol moderation: Maximum 100g/week of pure alcohol (approximately 7-12 standard drinks)
- Smoking cessation: Complete cessation of tobacco use
These lifestyle interventions can reduce blood pressure by 5-10 mmHg and enhance the effects of pharmacological treatment 1, 2.
Pharmacological Therapy
When lifestyle modifications alone are insufficient to achieve blood pressure control:
First-line medications include:
- ACE inhibitors (e.g., enalapril)
- Angiotensin receptor blockers (ARBs) (e.g., candesartan)
- Calcium channel blockers (CCBs) (e.g., amlodipine)
- Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)
Treatment thresholds:
- Initiate pharmacological therapy when BP ≥140/90 mmHg for most patients
- Consider earlier initiation (BP 130-139/80-89 mmHg) for high-risk patients (10-year CVD risk ≥10%)
Treatment targets:
- <130/80 mmHg for adults under 65 years
- 120-129 mmHg systolic for adults ≥65 years (if tolerated)
Special Considerations
- Combination therapy: More than 70% of hypertensive patients will eventually require at least two antihypertensive agents for adequate blood pressure control 2
- Renal disease: ACE inhibitors or ARBs are preferred first-line agents in patients with albuminuria (≥30 mg/g creatinine) 1
- Race: Black patients may benefit from calcium channel blockers as first-line therapy 2
- Elderly patients: More gradual dose titration with careful monitoring for orthostatic hypotension 2
Common Pitfalls
- Inadequate lifestyle counseling: Many clinicians underemphasize the importance of lifestyle modifications
- Therapeutic inertia: Failing to intensify treatment when blood pressure goals are not met
- Medication combinations: Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury without added benefit 2
- Monitoring: Failing to monitor renal function and electrolytes when using ACE inhibitors or ARBs 2
- Adherence: Poor medication adherence affects 10-80% of hypertensive patients and is a key driver of suboptimal BP control 1
Follow-up
- Follow up within 2-4 weeks after starting or changing medications
- Monitor blood pressure, renal function, and electrolytes regularly
- For patients on ACE inhibitors, ARBs, or diuretics, check serum creatinine/eGFR and potassium at least annually 1, 2
Remember that lifestyle modifications should be continued even when blood pressure-lowering medications are prescribed, as they enhance the efficacy of pharmacological therapy and provide additional cardiovascular benefits 2, 3.