What is the first-line treatment for a white middle-aged man with newly diagnosed hypertension?

First-Line Treatment for Hypertension in a White Middle-Aged Man

For a white middle-aged man with newly diagnosed hypertension, a thiazide-type diuretic is the recommended first-line treatment. 1

Rationale for Thiazide Diuretics as First Choice

Thiazide diuretics have the strongest evidence supporting their use as initial therapy for hypertension in this demographic:

• Systematic reviews with meta-analyses have shown that low-dose thiazide diuretics reduce all-cause mortality in hypertensive patients, preventing approximately 2-3 deaths and 2 strokes per 100 patients treated for 4-5 years 1
• Chlorthalidone specifically has high-level evidence from three large comparative clinical trials with over 50,000 patients 1
• Thiazide diuretics are more effective in lowering BP in white patients compared to other racial groups 2
• The 2020 ACC/AHA guidelines recommend thiazide diuretics as one of the first-line agents for hypertension 2

Medication Selection Algorithm

1. First choice: Thiazide diuretic (chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 25-50 mg daily)

   • Chlorthalidone is preferred due to stronger outcome data 1
   • If chlorthalidone is unavailable, hydrochlorothiazide is an acceptable alternative

2. Alternative first-line options (if thiazide diuretics are contraindicated):

   • ACE inhibitor (such as lisinopril) 3
   • Calcium channel blocker (such as amlodipine) 4
   • Angiotensin receptor blocker (ARB)

Dosing Considerations

• Start with low doses and titrate upward based on blood pressure response
• For chlorthalidone: Start with 12.5 mg daily, can increase to 25 mg daily
• For hydrochlorothiazide: Start with 12.5-25 mg daily, can increase to 50 mg daily

Monitoring and Follow-up

• Check blood pressure within 2-4 weeks of starting therapy
• Monitor electrolytes (particularly potassium) and renal function within 1-2 weeks of starting therapy
• Assess for adverse effects including electrolyte disturbances, especially hypokalemia
• Be aware that thiazide diuretics can cause hyperglycemia and diabetes, though this does not reduce their efficacy in preventing cardiovascular events 1

Special Considerations

• If the patient has comorbidities like diabetes with albuminuria or chronic kidney disease, an ACE inhibitor or ARB may be preferred 2
• If blood pressure remains uncontrolled on monotherapy, adding a calcium channel blocker or ACE inhibitor/ARB would be appropriate 2
• For patients with blood pressure ≥160/100 mmHg, consider initiating therapy with two antihypertensive medications 2

Common Pitfalls to Avoid

• Underdosing thiazide diuretics: For optimal cardiovascular protection, chlorthalidone should be dosed at 12.5-25 mg daily 2
• Failing to monitor electrolytes after initiating therapy
• Not considering combination therapy for patients with significantly elevated blood pressure
• Neglecting lifestyle modifications which should accompany pharmacological treatment

Remember that lifestyle modifications (weight reduction, DASH diet, sodium restriction, physical activity, and alcohol moderation) should be implemented alongside pharmacological therapy 2, 5.