What are the typical first-line treatments and lifestyle modifications for managing hypertension?

First-Line Treatments and Lifestyle Modifications for Managing Hypertension

The first-line treatment for hypertension includes lifestyle modifications followed by pharmacological therapy with thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers when blood pressure remains elevated despite lifestyle changes. 1

Lifestyle Modifications

Lifestyle modifications are the cornerstone of hypertension management and should be implemented for all patients:

Diet

• DASH Diet: Rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced saturated and total fat content 2, 1
• Sodium Restriction: Limit to 2.4g sodium (6g salt) per day 2, 1
• Potassium Intake: Increase dietary potassium (3500-5000 mg/day) through foods like fruits and vegetables 2, 1
• Limit Sugar: Especially sugar-sweetened beverages 1

Physical Activity

• Regular Exercise: 150 minutes/week of moderate-intensity aerobic activity (30 minutes, 5 days/week) or 75 minutes/week of vigorous exercise 2, 1
• Resistance Training: 2-3 sessions per week as a complement to aerobic exercise 1

Weight Management

• Weight Reduction: Maintain normal body weight (BMI 20-25 kg/m²) 2, 1
• Waist Circumference: Target <94 cm in men, <80 cm in women 1
• Even modest weight loss of 10 lbs (4.5 kg) can significantly reduce blood pressure 2

Alcohol Moderation

• Men: Limit to no more than 2 standard drinks per day (maximum 14/week) 2, 1
• Women: Limit to no more than 1 standard drink per day (maximum 9/week) 2, 1

Smoking Cessation

• Complete cessation of tobacco use is strongly recommended 2, 1

Blood Pressure Reduction from Lifestyle Modifications

Modification	Approximate SBP Reduction
Weight reduction	5-20 mmHg per 10 kg weight loss
DASH diet	8-14 mmHg
Sodium reduction	2-8 mmHg
Physical activity	4-9 mmHg
Alcohol moderation	2-4 mmHg

Pharmacological Treatment

When lifestyle modifications alone are insufficient to achieve blood pressure goals, medication therapy should be initiated:

First-Line Medications 1, 3

1. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)
2. ACE inhibitors (e.g., lisinopril) 4
3. ARBs (e.g., candesartan)
4. Calcium channel blockers (e.g., amlodipine) 5

Patient-Specific Considerations

• Diabetes with albuminuria: ACE inhibitors or ARBs preferred 1
• Chronic kidney disease: ACE inhibitors or ARBs preferred 1
• Heart failure: ACE inhibitors, ARBs, or beta-blockers preferred 1
• Black patients: Calcium channel blockers or thiazide diuretics may be more effective 1
• Elderly patients: More gradual dose titration with careful monitoring for orthostatic hypotension 1

Combination Therapy

• More than 70% of hypertensive patients will eventually require at least two antihypertensive medications 1
• Effective combinations include:
  • ACE inhibitor or ARB + calcium channel blocker
  • ACE inhibitor or ARB + thiazide diuretic
  • Calcium channel blocker + thiazide diuretic
• Single-pill combinations improve adherence 1
• Important: Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury 1

Treatment Goals

• General population: <140/90 mmHg 1
• High-risk patients (diabetes, CKD, high CVD risk): <130/80 mmHg 1
• Adults under 65 years: 120-129 mmHg systolic if tolerated 1
• Adults 65 years and older: 130-139 mmHg systolic 1

Follow-Up and Monitoring

• Monthly follow-up after medication initiation or changes until target BP is reached 1
• Every 3-5 months for patients with controlled BP 1
• Monitor serum creatinine/eGFR and potassium at baseline and at least annually for patients on ACE inhibitors, ARBs, or diuretics 1

Common Pitfalls to Avoid

1. Inadequate lifestyle counseling: Many patients do not receive sufficient guidance on diet, exercise, and other lifestyle modifications 2
2. Monotherapy limitations: Most patients will eventually require combination therapy 1
3. Medication adherence issues: Once-daily dosing improves adherence compared to multiple daily doses 2
4. Inappropriate combinations: Never combine ACE inhibitors with ARBs 1
5. Overlooking secondary causes: Consider sleep apnea, primary aldosteronism, or renal artery stenosis in resistant hypertension 2
6. Ignoring white coat hypertension: Home BP monitoring can help identify this condition 2

By implementing these evidence-based lifestyle modifications and medication strategies, most patients with hypertension can achieve adequate blood pressure control and reduce their risk of cardiovascular events.