What is the initial approach to starting antihypertensive therapy in a newly diagnosed patient with Hypertension (High Blood Pressure)?

Initial Approach to Antihypertensive Therapy in Newly Diagnosed Hypertension

For newly diagnosed hypertension, initial therapy should be based on hypertension stage, cardiovascular risk, and comorbidities, with thiazide-type diuretics (preferably chlorthalidone) as the preferred first-line agent for most patients with uncomplicated hypertension. 1, 2

Assessment and Classification

First, determine the hypertension stage:

• Elevated BP: 120-129/<80 mmHg
• Stage 1 Hypertension: 130-139/80-89 mmHg
• Stage 2 Hypertension: ≥140/90 mmHg
• Hypertensive Crisis: >180/>120 mmHg

Treatment Algorithm Based on BP Stage

Elevated BP (120-129/<80 mmHg)

• Implement lifestyle modifications only
• Follow-up in 3-6 months

Stage 1 Hypertension (130-139/80-89 mmHg)

• Calculate 10-year ASCVD risk using ACC/AHA Pooled Cohort Equations
• If ASCVD risk <10%:
  • Lifestyle modifications only
  • Follow-up in 3-6 months
• If ASCVD risk ≥10%:
  • Lifestyle modifications + single antihypertensive drug
  • Follow-up in 1 month

Stage 2 Hypertension (≥140/90 mmHg)

• Lifestyle modifications + two antihypertensive drugs from different classes
• Follow-up in 1 month

Very High BP (≥180/≥110 mmHg)

• Immediate evaluation
• Prompt antihypertensive drug therapy
• Assess for end-organ damage
• If end-organ damage present (hypertensive emergency): hospitalization and IV medications
• If no end-organ damage (hypertensive urgency): oral medications with close follow-up

First-Line Medication Selection

For most patients with uncomplicated hypertension, thiazide-type diuretics are the preferred first-line therapy, particularly chlorthalidone (12.5-25 mg daily) due to its proven ability to reduce cardiovascular morbidity and mortality 1, 2, 3.

Alternative first-line options include:

• ACE inhibitors (e.g., lisinopril 10 mg daily)
• ARBs (e.g., losartan 50 mg daily)
• Calcium channel blockers (CCBs)

Special Populations

• Black patients: Thiazide diuretics or CCBs preferred
• Diabetes: ACE inhibitors or ARBs preferred
• Chronic kidney disease: ACE inhibitors or ARBs preferred
• Heart failure: ACE inhibitors, ARBs, or beta-blockers preferred
• Coronary artery disease: Beta-blockers, ACE inhibitors preferred

Medication Initiation Guidelines

Thiazide Diuretics

• Start chlorthalidone 12.5 mg daily (preferred) or hydrochlorothiazide 25 mg daily
• Check electrolytes and renal function 2-4 weeks after initiation
• Maximum dose: chlorthalidone 25 mg or hydrochlorothiazide 50 mg daily

ACE Inhibitors

• Start lisinopril 10 mg daily 4
• Check electrolytes and renal function 2-4 weeks after initiation
• Titrate to 20-40 mg daily based on response
• Avoid in pregnancy and history of angioedema

ARBs

• Start losartan 50 mg daily 5
• Check electrolytes and renal function 2-4 weeks after initiation
• Titrate to 100 mg daily based on response
• Alternative to ACE inhibitors if cough develops

Combination Therapy

For Stage 2 hypertension, initiate with two drugs from different classes:

• Thiazide diuretic + ACE inhibitor/ARB
• Thiazide diuretic + CCB
• ACE inhibitor/ARB + CCB

Do not combine ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 2.

Follow-Up and Monitoring

• Stage 1 hypertension with drug therapy: Follow-up in 1 month
• Stage 2 hypertension: Follow-up in 1 month
• After BP control achieved: Follow-up every 3-6 months
• Monitor for:
  • Blood pressure response
  • Medication adherence
  • Side effects
  • Electrolyte abnormalities with diuretics
  • Renal function with ACE inhibitors/ARBs

Common Pitfalls to Avoid

1. Inappropriate combinations: Avoid combining ACE inhibitors with ARBs
2. Neglecting lifestyle modifications: Diet, exercise, and sodium restriction remain essential
3. Inaccurate BP measurement: Ensure proper technique and equipment
4. Therapeutic inertia: Don't delay intensifying treatment when BP remains uncontrolled
5. Overlooking secondary causes: Consider screening for secondary hypertension in resistant cases or young patients

Target Blood Pressure

For most adults: <130/80 mmHg For older adults (≥65 years): SBP <130 mmHg if tolerated

By following this structured approach to initiating antihypertensive therapy, you can effectively manage newly diagnosed hypertension and reduce cardiovascular risk.