Initial Treatment Approach for Hypertension
The initial treatment approach for hypertension should begin with lifestyle modifications, followed by pharmacological therapy with ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics based on patient characteristics if blood pressure targets are not achieved. 1
Diagnosis and Blood Pressure Targets
Diagnosis confirmed when:
- Home BP readings ≥135/85 mmHg
- 24-hour ambulatory BP readings ≥130/80 mmHg
- Office readings consistently ≥140/90 mmHg 1
Target blood pressure:
- General population: <140/90 mmHg
- High-risk patients (diabetes, CKD, established CVD): <130/80 mmHg 1
Step 1: Lifestyle Modifications
Lifestyle modifications are the foundation of hypertension management and can significantly reduce blood pressure:
| Modification | Approximate Reduction in Systolic BP |
|---|---|
| Weight loss | 5-20 mmHg per 10 kg lost |
| DASH diet | 8-14 mmHg |
| Sodium reduction | 2-8 mmHg |
| Physical activity | 4-9 mmHg |
| Moderate alcohol | 2-4 mmHg |
Key lifestyle interventions include:
- Weight reduction: Target healthy BMI (5-20 mmHg reduction per 10kg lost) 1
- DASH diet: Rich in fruits, vegetables, whole grains (8-14 mmHg reduction) 1
- Sodium restriction: Limit to 2.4g per day (2-8 mmHg reduction) 1
- Regular exercise: 150 minutes/week of moderate-intensity activity (4-9 mmHg reduction) 1
- Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women (2-4 mmHg reduction) 1
- Smoking cessation: Important for overall cardiovascular risk reduction 1
Step 2: Pharmacological Therapy
If lifestyle modifications fail to achieve target BP within 3-6 months or if initial BP is significantly elevated, add pharmacological therapy:
First-line Medications
- ACE inhibitors (e.g., lisinopril): Initial dose 10 mg once daily, usual range 20-40 mg 1, 2
- ARBs (e.g., losartan): Initial dose 50 mg once daily, maximum 100 mg 1, 3
- Calcium channel blockers (dihydropyridines like amlodipine)
- Thiazide/thiazide-like diuretics (e.g., hydrochlorothiazide) 1, 4
Patient-Specific First-Line Recommendations:
- Black patients: Calcium channel blocker or thiazide diuretic 1
- Non-black patients: ACE inhibitor or ARB 1
- Diabetic patients with albuminuria: ACE inhibitor or ARB 1
- Heart failure patients: ACE inhibitor, ARB, or beta-blocker 1
- CKD patients: ACE inhibitor to slow kidney disease progression 1
- Elderly patients: More gradual dose titration with careful monitoring for orthostatic hypotension 1
- Pregnant women: Avoid ACE inhibitors and ARBs due to fetal risk 1
Combination Therapy
More than 70% of hypertensive patients will eventually require at least two antihypertensive agents for adequate BP control 1. Important considerations:
- If BP remains uncontrolled on a single agent at maximum tolerated dose, add a second agent from a different class
- Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury without added benefit 1
- Consider adding a low-dose diuretic if BP is not controlled with ACE inhibitor or ARB alone 2, 3
Monitoring and Follow-up
- Follow up within 2-4 weeks after initiating treatment 1
- Monitor BP monthly until target is reached, then every 3-5 months 1
- Check serum creatinine/eGFR and potassium at baseline and periodically for patients on ACE inhibitors, ARBs, or diuretics 1
Common Pitfalls to Avoid
- Therapeutic inertia: Failure to intensify treatment when BP targets are not met
- White coat hypertension: Relying solely on office BP measurements
- Inadequate dosing: Not titrating medications to effective doses
- Medication non-adherence: Not addressing barriers to adherence
- Ignoring lifestyle modifications: Focusing only on pharmacological therapy 1
Remember that achieving BP control to target levels is associated with significantly lower rates of stroke, myocardial infarction, and heart failure 1.