What are the first-line medications for treating hypertension, as recommended by the European Society of Cardiology (ESC) in Class I indications?

From the Guidelines

The first-line medications for treating hypertension, as recommended by the European Society of Cardiology (ESC) in Class I indications, are ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics (thiazides and thiazide-like drugs), which have demonstrated the most effective reduction of BP and CVD events. According to the ESC guidelines 1, these medications are recommended as first-line treatments to lower BP. The guidelines suggest that among all BP-lowering drugs, these classes have demonstrated the most effective reduction of BP and CVD events. Some key points to consider when treating hypertension include:

• The preferred approach is often to start with a combination of two drugs, typically an ACEI or ARB combined with either a CCB or diuretic, as this provides more rapid, efficient, and consistent blood pressure control 1.
• Beta-blockers are generally recommended to be combined with any of the other major BP-lowering drug classes when there are other compelling indications for their use, e.g. angina, post-myocardial infarction, heart failure with reduced ejection fraction, or for heart rate control 1.
• Fixed-dose single-pill combination treatment is recommended for patients receiving combination BP-lowering treatment 1.
• If BP is not controlled with a two-drug combination, increasing to a three-drug combination is recommended, usually a RAS blocker with a dihydropyridine CCB and a thiazide/thiazide-like diuretic, and preferably in a single-pill combination 1. These recommendations are based on extensive clinical evidence showing these medications effectively lower blood pressure and reduce cardiovascular morbidity and mortality, with generally favorable safety profiles when appropriately prescribed 1.

From the Research

First-Line Medications for Hypertension

The European Society of Cardiology (ESC) recommends the following first-line medications for treating hypertension in Class I indications:

• Thiazide diuretics 2, 3
• Calcium channel blockers 4, 5
• Angiotensin-converting enzyme inhibitors (ACEIs) 6, 5
• Angiotensin receptor blockers (ARBs) 6, 3, 5

Key Considerations

When selecting a first-line medication, the following factors should be considered:

• The patient's demographic characteristics, such as age and ethnicity 6
• The presence of comorbidities, such as diabetes, heart failure, or chronic kidney disease 6, 4, 5
• The potential for adverse effects and interactions with other medications 2, 4, 5

Combination Therapy

Combination therapy may be necessary for patients who do not respond to monotherapy or who have multiple comorbidities 6, 3. The ESC recommends using a combination of medications from different classes, such as:

• Thiazide diuretics and ACEIs or ARBs 6, 3
• Calcium channel blockers and ACEIs or ARBs 4, 5

Evidence-Based Recommendations

The recommendations for first-line medications are based on evidence from numerous studies, including:

• A study published in the American Family Physician in 2020, which discussed the use of combination therapy for hypertension 6
• A Cochrane review published in 2023, which compared the effects of first-line diuretic drugs with other antihypertensive drug classes 2
• A study published in the Progress in Cardiovascular Diseases in 2001, which discussed the use of calcium channel blockers in the treatment of hypertension 4
• A study published in the International Journal of Clinical Practice in 2007, which discussed the use of irbesartan/hydrochlorothiazide combination therapy for hypertension 3
• A review article published in the Vascular Health and Risk Management in 2022, which discussed the use of angiotensin receptor blockers in the management of hypertension 5