What are the recommended initial treatments for managing hypertension?

Initial Treatment Recommendations for Hypertension Management

For patients with hypertension, first-line treatment should include lifestyle modifications plus pharmacological therapy with either a thiazide/thiazide-like diuretic, ACE inhibitor, ARB, or dihydropyridine calcium channel blocker, with combination therapy recommended for blood pressure ≥140/90 mmHg. 1, 2

Lifestyle Modifications (First-Line for All Patients)

All patients with hypertension should implement the following lifestyle changes:

• Dietary modifications:

  • Follow DASH (Dietary Approaches to Stop Hypertension) eating pattern 2, 1
  • Reduce sodium intake (<2,300 mg/day) 2, 1
  • Increase potassium intake through fruits and vegetables 1, 3
  • Moderate alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) 2, 1

• Physical activity:

  • 150 minutes/week of moderate-intensity aerobic activity 2, 1
  • 2-3 sessions/week of resistance training 1

• Weight management:

  • Achieve and maintain healthy body weight (BMI 20-25 kg/m²) 1, 3

• Smoking cessation 1, 4

Pharmacological Treatment Algorithm

Step 1: Initial Assessment

Determine blood pressure severity:

• BP 130/80-139/89 mmHg: Start with lifestyle modifications; add medication if high cardiovascular risk, diabetes, chronic kidney disease, or established cardiovascular disease 1
• BP 140/90-159/99 mmHg: Start lifestyle modifications + single antihypertensive agent 2
• BP ≥160/100 mmHg: Start lifestyle modifications + two-drug combination therapy 2, 1

Step 2: First-Line Medication Selection

Choose from these evidence-based options:

1. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone, indapamide) 2, 1

   • Starting dose: hydrochlorothiazide 12.5-25 mg once daily 5

2. ACE inhibitors (e.g., lisinopril) 2, 1

   • Starting dose: lisinopril 10 mg once daily 6

3. Angiotensin receptor blockers (ARBs) 2, 1

   • Particularly if ACE inhibitor not tolerated (cough)

4. Dihydropyridine calcium channel blockers (e.g., amlodipine) 2, 1

Step 3: Special Population Considerations

Modify initial medication choice based on comorbidities:

• Diabetes with albuminuria: Start with ACE inhibitor or ARB 2, 1
• Chronic kidney disease: Start with ACE inhibitor or ARB 1
• Established coronary artery disease: Start with ACE inhibitor or ARB 2, 1
• Black patients: Start with thiazide diuretic or calcium channel blocker 2, 1
• Heart failure: ACE inhibitor/ARB + beta-blocker + diuretic 2, 1

Step 4: Combination Therapy Approach

For BP ≥140/90 mmHg or if monotherapy inadequate:

• Preferred combinations: 1
  • ACE inhibitor or ARB + calcium channel blocker
  • ACE inhibitor or ARB + thiazide diuretic
  • Calcium channel blocker + thiazide diuretic

Blood Pressure Targets

• Standard target: SBP 120-129 mmHg and DBP <80 mmHg for most adults 2, 1
• Modified targets:
  • Age ≥65 years: SBP 130-139 mmHg 2
  • Frail elderly or those with orthostatic hypotension: <140/90 mmHg 2, 1

Monitoring and Follow-up

• Monitor BP response 2-4 weeks after initiating or changing therapy 1
• Monitor serum creatinine and potassium when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2
• Assess medication adherence at each visit 1
• Aim to achieve BP target within 3 months 1

Common Pitfalls to Avoid

1. Inadequate initial therapy: Starting with monotherapy when BP ≥160/100 mmHg (use combination therapy) 2, 1

2. Inappropriate combinations: Combining ACE inhibitors with ARBs (increases adverse effects without additional benefit) 2, 1

3. Insufficient lifestyle counseling: Lifestyle modifications should continue even after starting medications 3, 4

4. Overlooking home BP monitoring: Out-of-office measurements help confirm diagnosis and monitor treatment effectiveness 1

5. Failure to adjust therapy: Not intensifying treatment when BP remains above target 1