What are the first-line treatments for managing hypertension?

First-Line Treatments for Managing Hypertension

The first-line treatments for managing hypertension include lifestyle modifications and pharmacological therapy with ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers, with combination therapy recommended for blood pressure ≥150/90 mmHg. 1

Lifestyle Modifications

Lifestyle modifications are essential components of hypertension management and should be implemented for all patients with blood pressure >120/80 mmHg:

• Weight management: Achieve and maintain a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Dietary approach: Follow a DASH-style eating pattern 1
  • Reduce sodium intake (<2,300 mg/day)
  • Increase potassium intake (8-10 servings of fruits and vegetables per day)
  • Increase low-fat dairy consumption (2-3 servings per day)
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week, complemented with resistance training 2-3 times weekly 1
• Alcohol moderation: No more than 2 drinks/day for men and 1 drink/day for women 1
• Smoking cessation: Complete avoidance of tobacco products 1

These lifestyle interventions can lower blood pressure, enhance the effectiveness of antihypertensive medications, and promote overall cardiovascular health 1.

Pharmacological Treatment

Initial Drug Selection

For patients with confirmed hypertension (≥140/90 mmHg), pharmacological therapy should be initiated promptly along with lifestyle modifications. First-line drug classes include:

1. ACE inhibitors (e.g., lisinopril) 1, 2
2. ARBs (e.g., losartan) 1, 3
3. Thiazide-like diuretics (e.g., chlorthalidone, indapamide) 1
4. Dihydropyridine calcium channel blockers (e.g., amlodipine) 1

Treatment Strategy Based on Blood Pressure Level

• BP between 130/80 and 150/90 mmHg: May begin with a single drug 1
• BP ≥150/90 mmHg: Initial treatment with two antihypertensive medications is recommended to achieve blood pressure goals more effectively 1
• Single-pill combinations are preferred to improve medication adherence 1

Special Considerations for Drug Selection

• Patients with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB is recommended as first-line therapy 1
• Patients with established coronary artery disease: ACE inhibitor or ARB is recommended as first-line therapy 1
• Black patients: Calcium channel blockers may be more effective as initial monotherapy 4

Monitoring and Follow-Up

• Monitor serum creatinine and potassium levels when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Check for hypokalemia when diuretics are used 1
• Laboratory monitoring should occur 7-14 days after initiation or dose changes of these medications 1
• Regular blood pressure monitoring both in office and at home is essential for treatment adjustment 1

Treatment of Resistant Hypertension

For patients with resistant hypertension (BP uncontrolled despite three medications):

1. Reinforce lifestyle measures, especially sodium restriction 1
2. Add low-dose spironolactone to existing treatment 1
3. If spironolactone is not tolerated, consider eplerenone, amiloride, higher-dose thiazide diuretic, or loop diuretic 1
4. Additional options include bisoprolol or doxazosin 1

Important Cautions

• ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy and should be avoided in women of childbearing potential who are not using reliable contraception 1
• Combinations of ACE inhibitors and ARBs should not be used due to increased risk of adverse effects without additional benefits 1
• Beta-blockers are not recommended as first-line agents unless there are compelling indications such as coronary artery disease or heart failure 1, 4

The goal of hypertension management is to reduce cardiovascular morbidity and mortality through effective blood pressure control, with treatment decisions guided by blood pressure levels, presence of target organ damage, and overall cardiovascular risk.