What is the initial treatment approach for a patient with hypertension?

Initial Treatment Approach for Hypertension

The initial treatment for hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy with ACE inhibitors, ARBs, thiazide diuretics, or calcium channel blockers when blood pressure is between 130/80-160/100 mmHg, or two-drug therapy when BP ≥160/100 mmHg. 1

Diagnosis and Assessment

• Confirm hypertension diagnosis with repeated measurements or home/ambulatory monitoring
• BP ≥135/85 mmHg on home monitoring or ≥130/80 mmHg on 24-hour ambulatory monitoring confirms diagnosis 1
• Assess for:
  • Cardiovascular risk factors (diabetes, dyslipidemia, smoking, obesity)
  • Target organ damage (heart, kidney, eye, brain)
  • Orthostatic hypotension (measure BP in both supine and standing positions)

Step 1: Lifestyle Modifications

Lifestyle modifications are first-line therapy for all hypertensive patients and can produce significant BP reductions:

Modification	Approximate SBP Reduction
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 consumption	2-4 mmHg

1, 2

Step 2: Pharmacological Therapy

Initial Medication Selection

• First-line medication classes:

  • ACE inhibitors (e.g., lisinopril)
  • Angiotensin receptor blockers (ARBs) (e.g., losartan)
  • Thiazide or thiazide-like diuretics
  • Dihydropyridine calcium channel blockers 1, 2, 3

• Starting dosage:

  • For BP between 130/80-160/100 mmHg: Start with a single drug
  • For BP ≥160/100 mmHg: Start with two antihypertensive medications 1

Specific Medication Examples:

• Losartan (ARB):

  • Starting dose: 50 mg once daily
  • Can increase to maximum 100 mg once daily as needed
  • Lower starting dose (25 mg) for patients with possible intravascular depletion 4

• Lisinopril (ACE inhibitor):

  • Starting dose: 10 mg once daily
  • Usual dosage range: 20-40 mg per day
  • Lower starting dose (5 mg) for patients taking diuretics 5

Special Population Considerations

• Diabetic patients: ACE inhibitors or ARBs preferred, especially with albuminuria 1
• Heart failure patients: ACE inhibitors, ARBs, or beta-blockers 1
• CKD patients: ACE inhibitors to slow kidney disease progression 1
• Black patients: Calcium channel blocker as first-line therapy 1
• Elderly patients: More gradual dose titration with monitoring for orthostatic hypotension 1
• Pregnant women: Avoid ARBs due to risk of fetal damage 1
• Hepatic impairment: Reduced starting doses (e.g., losartan 25 mg daily) 4

Monitoring and Follow-up

• Follow up within 2-4 weeks to evaluate response to treatment 1
• Monitor BP monthly until target is reached, then every 3-5 months 1
• Check serum creatinine/eGFR and potassium at treatment initiation and periodically for patients on ACE inhibitors, ARBs, or diuretics 1

Common Pitfalls to Avoid

• Therapeutic inertia: Don't delay intensifying treatment when BP goals aren't met
• Ignoring lifestyle modifications: Continue to emphasize their importance alongside medications
• Inadequate dosing: Titrate medications to effective doses
• Medication non-adherence: Use single-pill combinations when possible to improve adherence
• Combining ACE inhibitors and ARBs: Never use simultaneously due to increased risk of hyperkalemia and acute kidney injury without added benefit 1

Remember that more than 70% of hypertensive patients will eventually require at least two antihypertensive agents for adequate BP control 1. The goal is to achieve BP control to <140/90 mmHg, which is associated with lower rates of stroke, myocardial infarction, and heart failure 1.