When should blood pressure medications be started in patients with hypertension?

When to Start Blood Pressure Medications

Blood pressure medications should be initiated when blood pressure is ≥140/90 mmHg (stage 1 hypertension) or ≥130/80 mmHg in patients with diabetes, chronic kidney disease, or high cardiovascular risk, after appropriate assessment of cardiovascular risk profile and comorbidities. 1

Blood Pressure Thresholds for Medication Initiation

General Population

• Stage 1 Hypertension (140-159/90-99 mmHg):
  • Start with single-agent therapy, preferably a thiazide diuretic
  • Goal: Achieve BP <130/80 mmHg for most adults 1

Stage 2 Hypertension (≥160/100 mmHg)

• Initiate two-drug combination therapy immediately
• Usually a thiazide-type diuretic plus an ACE inhibitor, ARB, beta-blocker, or CCB 1

Special Populations

• Diabetes or Chronic Kidney Disease: Start medications at BP ≥130/80 mmHg 1
• High Cardiovascular Risk: Consider lower threshold (≥130/80 mmHg) for initiation 2
• Older Adults (≥65 years): Target SBP <130 mmHg if tolerated 1
• Frail Elderly: Consider less aggressive targets based on clinical judgment 1

First-Line Medication Selection

Preferred Initial Agents

• First choice for most patients: Thiazide or thiazide-type diuretics (preferably chlorthalidone)
  • Proven to reduce cardiovascular morbidity and mortality 1
  • Most effective in preventing heart failure compared to other classes 1

Population-Specific Recommendations

• Black patients: Thiazide diuretic or CCB 1, 3
• Heart Failure: ACE inhibitor, ARB, or beta-blocker 1, 3
• Chronic Kidney Disease with proteinuria: ACE inhibitor or ARB 1, 3
• Diabetes: ACE inhibitor or ARB (especially with proteinuria) 1, 3

Dosing Considerations

For example, with lisinopril (an ACE inhibitor):

• Initial dose: 10 mg once daily for hypertension
• Adjust according to blood pressure response
• Usual range: 20-40 mg per day 4
• For patients already on diuretics: Start with lower dose (5 mg) 4

Combination Therapy Approach

• Initial BP >20/10 mmHg above goal: Consider starting with combination therapy 1
• If monotherapy fails: Add a second agent from a complementary class 3
• More than 70% of patients will eventually require at least two antihypertensive agents 3
• Preferred combinations:
  • ACE inhibitor or ARB plus a thiazide diuretic
  • ACE inhibitor or ARB plus a CCB 1

Monitoring After Initiation

• Follow up every 2-4 weeks initially to assess response
• Check renal function and electrolytes 2-4 weeks after starting diuretics
• Once target BP is reached, follow up every 3-5 months 1

Lifestyle Modifications

Always recommend alongside medication:

• Sodium restriction (5-6 g of salt per day)
• Weight reduction (targeting BMI of 25 kg/m²)
• Physical activity (30 minutes, 5-7 days per week)
• Limit alcohol consumption
• DASH diet (rich in fruits, vegetables, and low-fat dairy products) 1

Common Pitfalls to Avoid

1. Inappropriate combinations: Never combine ACE inhibitors with ARBs 1
2. Overlooking lifestyle modifications: These can significantly enhance medication efficacy 1
3. Inaccurate BP measurement: Ensure proper technique for diagnosis and monitoring 1
4. Therapeutic inertia: Don't delay intensifying treatment when BP remains uncontrolled 1
5. Pseudoresistant hypertension: Rule out "white coat" hypertension before escalating therapy 1

The decision to start antihypertensive medication should be based on accurate BP measurements, cardiovascular risk assessment, and the presence of comorbidities, with the primary goal of reducing cardiovascular morbidity and mortality through achieving appropriate BP targets.