What is the first line treatment for Hypertension (HTN)?

First-Line Treatment for Hypertension

First-line treatment for hypertension includes thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, and dihydropyridine calcium channel blockers, with selection based on patient characteristics. 1, 2

Medication Selection Algorithm

Step 1: Initial Medication Selection

• For most patients: Start with one of the following:
  • ACE inhibitor (e.g., lisinopril)
  • ARB (e.g., losartan)
  • Thiazide or thiazide-like diuretic (e.g., chlorthalidone, hydrochlorothiazide)
  • Dihydropyridine calcium channel blocker (e.g., amlodipine)

Step 2: Patient-Specific Considerations

• Black patients: Start with a thiazide/thiazide-like diuretic or calcium channel blocker 1
• Patients with albuminuria or CKD: Prefer ACE inhibitor or ARB 3
• Patients with coronary artery disease: Prefer ACE inhibitor or ARB 3
• Patients with diabetes and albuminuria: ACE inhibitor or ARB is strongly recommended 3

Step 3: Blood Pressure Severity Assessment

• BP 130-159/80-99 mmHg: Start with a single agent 3
• BP ≥160/100 mmHg: Start with two agents (either as separate pills or fixed-dose combination) 3

Medication Efficacy and Selection Rationale

The most recent guidelines consistently recommend four main classes of medications as first-line therapy for hypertension:

1. ACE inhibitors (e.g., lisinopril): Effective for reducing cardiovascular events, particularly beneficial in patients with diabetes, CKD, or coronary artery disease 4

2. ARBs (e.g., losartan): Similar efficacy to ACE inhibitors but with fewer adverse effects such as cough 5, 6

3. Thiazide/thiazide-like diuretics: Long-acting agents like chlorthalidone and indapamide are preferred due to their proven efficacy in reducing cardiovascular events 3

4. Dihydropyridine calcium channel blockers: Effective blood pressure reduction with favorable side effect profile 3

Special Considerations

Compelling Indications

• Heart failure: ACE inhibitors or ARBs are preferred 4
• Post-myocardial infarction: ACE inhibitors are indicated 4
• Chronic kidney disease with proteinuria: ACE inhibitors or ARBs are strongly recommended 5

Monitoring Requirements

• For patients on ACE inhibitors, ARBs, or diuretics:
  • Monitor serum creatinine/eGFR and potassium levels at least annually 3
  • Check these values within 2-4 weeks of initiating therapy or changing doses

Combination Therapy

• Many patients will require multiple medications to achieve blood pressure targets 3
• Important caution: Do not combine ACE inhibitors with ARBs due to increased risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 3, 1

Lifestyle Modifications

Lifestyle modifications should be implemented alongside pharmacological therapy:

• Sodium restriction (<2,300 mg/day)
• DASH or Mediterranean diet
• Regular physical activity (150 minutes/week of moderate-intensity exercise)
• Weight management
• Limited alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women)
• Smoking cessation 1

Treatment Targets

• General target: <130/80 mmHg for most adults 3
• Older adults (≥65 years): Target systolic BP <130 mmHg if tolerated 2

Common Pitfalls to Avoid

1. Inadequate dosing: Ensure timely titration of medications to achieve target BP
2. Ignoring home BP readings: Incorporate home BP monitoring for better assessment
3. Combining ACE inhibitors and ARBs: This combination increases adverse effects without additional benefit
4. Overlooking secondary causes: Consider screening for secondary hypertension in resistant cases
5. Neglecting lifestyle modifications: These can significantly enhance the efficacy of pharmacological therapy

By following this algorithm and considering patient-specific factors, clinicians can optimize hypertension management to reduce morbidity and mortality from cardiovascular disease.