What is the recommended initial therapy for stage 1 hypertension in otherwise healthy individuals with no compelling indications?

Initial Therapy for Stage 1 Hypertension in Otherwise Healthy Individuals

For stage 1 hypertension in otherwise healthy individuals with no compelling indications, thiazide-type diuretics, particularly chlorthalidone, are the recommended initial therapy according to the latest hypertension guidelines. 1

Treatment Algorithm for Stage 1 Hypertension

1. Confirm diagnosis of stage 1 hypertension:

   • Systolic BP 140-159 mmHg or
   • Diastolic BP 90-99 mmHg

2. Assess cardiovascular risk:

   • If 10-year ASCVD risk <10%: Begin with lifestyle modifications alone and reassess in 3-6 months
   • If 10-year ASCVD risk ≥10%: Initiate pharmacological therapy along with lifestyle modifications 1

3. First-line pharmacological therapy (when indicated):

   • Thiazide-type diuretics (preferably chlorthalidone 12.5-25 mg daily) 1
   • Chlorthalidone is preferred due to its longer half-life and proven reduction in cardiovascular disease outcomes 1

Supporting Evidence

The 2017 ACC/AHA guidelines explicitly state that for stage 1 hypertension requiring pharmacological therapy, "thiazide-type diuretics for most" is the recommended approach 1. This recommendation is supported by multiple large clinical trials, including the landmark ALLHAT trial, which demonstrated that chlorthalidone was superior or equivalent to other agents in preventing cardiovascular outcomes 2.

The JNC 7 guidelines (referenced in 1) also recommend thiazide-type diuretics as initial therapy for most patients with uncomplicated hypertension, noting their proven efficacy in reducing cardiovascular morbidity and mortality.

Alternative First-Line Options

If thiazide diuretics cannot be used, other first-line options include:

• ACE inhibitors (e.g., lisinopril)
• ARBs (e.g., losartan)
• Calcium channel blockers

However, these should be considered as alternatives rather than preferred initial therapy in otherwise healthy individuals without compelling indications 1, 3.

Medication Dosing

• Chlorthalidone: Start at 12.5 mg daily, may increase to 25 mg daily if needed 4
• Hydrochlorothiazide: Start at 25 mg daily, may increase to 50 mg daily if needed 1

Important Considerations and Monitoring

• Monitor electrolytes (particularly potassium) and renal function 2-4 weeks after initiating thiazide diuretics 1
• Thiazide diuretics may cause hyperglycemia and metabolic abnormalities but this does not reduce their efficacy in preventing cardiovascular events 5
• Follow-up should occur within 1 month after initiating pharmacological therapy 1
• Target blood pressure should be <130/80 mmHg according to the most recent guidelines 3

Special Populations

While the question focuses on otherwise healthy individuals, it's worth noting that specific populations may benefit from alternative initial therapies:

• Black patients: Calcium channel blockers may be more effective as first-line therapy 3
• Patients with diabetes, CKD, or heart failure: ACE inhibitors or ARBs may be preferred 3

The evidence consistently supports thiazide-type diuretics as the optimal initial therapy for stage 1 hypertension in otherwise healthy individuals, based on their proven efficacy, safety profile, and cost-effectiveness.