What is the initial pharmacological management of hypertension in a patient not on any antihypertensive (blood pressure) medications?

Pharmacological Management of Hypertension in Patients Not on Antihypertensive Medications

For patients not currently on any antihypertensive medications, initial pharmacological therapy should include drugs from one of four first-line classes: thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, or long-acting dihydropyridine calcium channel blockers, with combination therapy recommended for patients with BP ≥160/100 mmHg. 1

Initial Assessment and Treatment Decision

Blood Pressure Thresholds for Starting Medication

• BP ≥140/90 mmHg: Initiate pharmacological treatment 1
• BP 130-139 mmHg systolic: Consider treatment if patient has:
  • Existing cardiovascular disease (strong recommendation)
  • Diabetes mellitus
  • Chronic kidney disease
  • High cardiovascular risk 1

Initial Drug Selection

Single-Agent Therapy (for BP 140-159/90-99 mmHg):

• First-line options (any of these classes can be used):
  • Thiazide/thiazide-like diuretics
  • ACE inhibitors (e.g., lisinopril starting at 10 mg daily) 2
  • ARBs
  • Long-acting dihydropyridine calcium channel blockers 1, 3

Combination Therapy (for BP ≥160/100 mmHg):

• Start with two drugs from different classes, preferably as a single-pill combination to improve adherence 1
• Recommended combinations:
  • ACE inhibitor + dihydropyridine calcium channel blocker
  • ACE inhibitor + thiazide diuretic
  • ARB + dihydropyridine calcium channel blocker
  • ARB + thiazide diuretic 1, 3

Population-Specific Considerations

For Black Patients:

• Preferred initial therapy: Thiazide diuretic or calcium channel blocker 1, 3
• If using combination therapy: Consider ARB + calcium channel blocker or calcium channel blocker + thiazide diuretic 3

For Patients with Diabetes:

• Preferred agents: ACE inhibitors or ARBs 1, 3
• For BP >140/90 mmHg: Consider initial combination therapy 1

For Patients with Chronic Kidney Disease:

• Preferred agents: ACE inhibitors or ARBs, particularly if albuminuria is present 1, 3

For Patients with Coronary Artery Disease:

• Preferred agents: ACE inhibitors or ARBs 1

Target Blood Pressure Goals

• General population: <140/90 mmHg 1
• Patients with cardiovascular disease: <130 mmHg systolic 1
• Patients with diabetes, CKD, or high CV risk: <130/80 mmHg 3

Follow-Up and Monitoring

• Initial follow-up: Monthly after starting medication until target BP is achieved 1, 3
• Once controlled: Follow-up every 3-5 months 1
• Laboratory monitoring: Check serum creatinine/eGFR and potassium within 3 months of starting ACE inhibitors, ARBs, or diuretics 3

Common Pitfalls to Avoid

1. Delayed intensification: Don't wait too long to add additional medications if BP remains uncontrolled
2. Inappropriate combinations: Never combine ACE inhibitors with ARBs 3
3. Overlooking adherence: Address medication adherence before adding more drugs 3
4. Inadequate dosing: Ensure proper dose titration before adding additional agents
5. Ignoring resistant hypertension: Consider adding a mineralocorticoid receptor antagonist for patients not meeting targets on three medications (including a diuretic) 1

Evidence Quality Considerations

The WHO guidelines provide strong recommendations based on moderate to high-quality evidence for initial drug selection 1. The American Diabetes Association guidelines offer specific recommendations for patients with diabetes 1. The most recent comprehensive guidance comes from Praxis Medical Insights, which synthesizes recommendations from multiple major societies 3.

The evidence consistently supports the efficacy of thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers as first-line agents, with the choice depending on patient characteristics and comorbidities.