What is the initial treatment for elevated blood pressure (hypertension)?

Initial Treatment for Elevated Blood Pressure (Hypertension)

The initial treatment for elevated blood pressure (hypertension) should include lifestyle modifications, with medication therapy recommended when office BP is ≥140/90 mmHg. 1

Lifestyle Modifications as First-Line Approach

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

• Weight management: 5-20 mmHg reduction per 10 kg lost 2
• DASH diet: Rich in fruits, vegetables, whole grains, and low-fat dairy (8-14 mmHg reduction) 2
• Sodium restriction: Limit dietary sodium (2-8 mmHg reduction) 2
• Physical activity: Regular exercise for 30 minutes most days (4-9 mmHg reduction) 2
• Alcohol moderation: No more than 2 standard drinks per day for men and 1.5 for women (2-4 mmHg reduction) 2
• Stress reduction techniques: Particularly for those with stress-related BP elevations 2

Pharmacological Treatment

When BP ≥140/90 mmHg, medication therapy should be initiated along with lifestyle modifications 1. First-line medication options include:

1. ACE inhibitors (e.g., lisinopril)
2. Angiotensin receptor blockers (ARBs)
3. Thiazide or thiazide-like diuretics
4. Calcium channel blockers (CCBs)

Special Population Considerations

• Black patients: Initial treatment should include a diuretic or CCB, either alone or in combination with a RAS blocker 1
• Diabetic patients: ACE inhibitors or ARBs are preferred, especially with albuminuria 2
• CKD patients: RAS blockers are recommended, particularly with proteinuria 1
• Heart failure patients: Treatment should include ACE inhibitor/ARB, beta-blocker, and diuretic/MRA as needed 1

Medication Dosing Example (Lisinopril)

For adults with hypertension starting lisinopril:

• Initial dose: 10 mg once daily
• Usual dosage range: 20-40 mg daily
• If adding to diuretic therapy: Start with 5 mg once daily
• Titrate according to BP response 3

Treatment Targets

• General population: Target BP <140/90 mmHg 1, 4
• Adults <65 years: Consider target BP <130/80 mmHg 4
• Adults ≥65 years: Consider target systolic BP <130 mmHg 4
• CKD patients: Target systolic BP 130-139 mmHg 1

Monitoring and Follow-up

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

Common Pitfalls to Avoid

• White coat hypertension: Consider home BP monitoring to confirm diagnosis 2
• Medication interactions: Be aware of interactions with NSAIDs, decongestants, and certain supplements 2
• Therapeutic inertia: Don't delay intensifying treatment when BP remains uncontrolled 2
• Poor adherence: Simplify medication regimens when possible and address patient concerns 2

Remember that more than 70% of hypertensive patients will eventually require at least two antihypertensive agents for adequate BP control 2. Never use ACE inhibitors and ARBs simultaneously due to increased risk of hyperkalemia and acute kidney injury without added benefit 2.