What treatment should be started for hypertension?

Treatment of Hypertension

First-line treatment for hypertension should include lifestyle modifications followed by pharmacological therapy with ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics when blood pressure remains ≥140/90 mmHg despite lifestyle changes. 1

Initial Assessment and Treatment Thresholds

• Blood pressure should be measured at every routine visit
• Confirm hypertension diagnosis with blood pressure readings on separate days 2
• Treatment thresholds:
  • Initiate pharmacological treatment when BP ≥140/90 mmHg 2
  • For patients with existing cardiovascular disease and SBP 130-139 mmHg, start pharmacological treatment 2
  • For high-risk patients without CVD (diabetes, CKD, high CVD risk) with SBP 130-139 mmHg, consider pharmacological treatment 2

Lifestyle Modifications (First-Line for All Patients)

• Dietary approaches:
  • DASH or Mediterranean diet
  • Sodium restriction to approximately 2g per day
  • Limit free sugar consumption, especially sugar-sweetened beverages 1
• Physical activity:
  • Moderate-intensity aerobic exercise ≥150 minutes/week
  • Resistance training 2-3 times/week 1
  • Regular exercise can reduce BP by approximately 5 mmHg 3
• Other modifications:
  • Target healthy BMI (20-25 kg/m²)
  • Limit alcohol consumption (maximum 100g/week)
  • Complete cessation of tobacco use 1

Pharmacological Therapy

First-Line Medications

• Four main drug classes with equal efficacy:
  1. ACE inhibitors (e.g., lisinopril)
  2. ARBs (e.g., candesartan)
  3. Calcium channel blockers (e.g., amlodipine)
  4. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone) 2, 1, 4

Treatment Strategy

1. Initial therapy:

   • Start with monotherapy for mild hypertension
   • Consider combination therapy (preferably single-pill) for moderate-severe hypertension 2
   • More than 70% of patients will eventually require at least two agents 1

2. Effective combinations:

   • ACE inhibitor or ARB + calcium channel blocker
   • ACE inhibitor or ARB + thiazide diuretic
   • Calcium channel blocker + thiazide diuretic 1

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

Blood Pressure Targets

• General population: <140/90 mmHg 2
• Patients with CVD: <130 mmHg systolic 2
• High-risk patients (diabetes, CKD): <130 mmHg systolic 2, 1
• Elderly patients (≥65 years): 120-129 mmHg systolic (if tolerated) 1
• Very elderly (>80 years): <140/80 mmHg with gradual dose titration 1

Special Populations

• Black patients: May benefit from calcium channel blocker as first-line therapy 1
• Diabetic patients: ACE inhibitors or ARBs preferred, especially with albuminuria 2, 1
• Patients with heart failure: ACE inhibitors indicated as adjunctive therapy 5
• Post-myocardial infarction: ACE inhibitors indicated to improve survival 5
• Pregnant women: Target BP 110-129/65-79 mmHg; ARBs contraindicated 1

Monitoring and Follow-up

• Follow up monthly after initiation or change in medications until target is reached 2
• Once controlled, follow up every 3-5 months 2
• For patients on ACE inhibitors, ARBs, or diuretics: check serum creatinine/eGFR and potassium at baseline and at least annually 1

Common Pitfalls to Avoid

• Neglecting to screen for secondary hypertension, especially in young adults
• Overly aggressive BP lowering in frail elderly, which can lead to falls
• Failing to monitor renal function when using ACE inhibitors or ARBs
• Using ACE inhibitors and ARBs simultaneously 1
• Delaying treatment in patients with stage 2 hypertension 2

By following this evidence-based approach to hypertension management, clinicians can effectively reduce cardiovascular morbidity and mortality in their patients.