What are the recommended initial treatments for managing hypertension?

Initial Treatment Recommendations for Hypertension

The recommended initial treatment for hypertension should include lifestyle modifications for all patients, with pharmacological therapy starting with a thiazide/thiazide-like diuretic, ACE inhibitor/ARB, or calcium channel blocker for most patients with BP ≥140/90 mmHg. 1

Blood Pressure Thresholds for Treatment

When to Start Medication

• BP ≥140/90 mmHg: Initiate drug therapy alongside lifestyle modifications 1
• BP ≥160/100 mmHg: Prompt initiation and timely titration of two drugs or a single-pill combination 1
• BP 130-139/80-89 mmHg: Consider treatment based on cardiovascular risk factors, target organ damage, or presence of diabetes 1

First-Line Lifestyle Modifications

All patients with hypertension should receive lifestyle modification recommendations:

• Dietary approach: DASH diet pattern with reduced sodium (<2,300 mg/day) and increased potassium intake 1, 2
• Physical activity: 150 minutes of moderate-intensity aerobic activity per week 1, 3
• Weight management: Achieve healthy BMI (20-25 kg/m²) and waist circumference (<94 cm for men, <80 cm for women) 1, 3
• Alcohol limitation: <14 units/week for men, <8 units/week for women 1
• Smoking cessation: Complete cessation recommended 1, 3

First-Line Pharmacological Therapy

The 2023 guidelines recommend the following first-line medications:

Standard First-Line Options

• Thiazide/thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)
• ACE inhibitors (e.g., lisinopril)
• ARBs (angiotensin receptor blockers)
• Dihydropyridine calcium channel blockers (e.g., amlodipine)

Population-Specific Recommendations

• Black patients: Initial treatment should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 1
• Patients with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB recommended as first-line 1
• Patients with established coronary artery disease: ACE inhibitor or ARB recommended as first-line 1

Medication Dosing Guidelines

• Lisinopril: Start at 10 mg once daily, usual range 20-40 mg daily 4
• Hydrochlorothiazide: Initial dose is one capsule daily, with total daily doses not exceeding 50 mg 5

Treatment Intensification Algorithm

1. Initial therapy: Start with one medication at low dose
2. If BP remains uncontrolled: Add a second medication from a different class or increase dose of initial medication
3. For BP ≥160/100 mmHg: Begin with two medications from complementary classes 1
4. If BP remains uncontrolled on three medications (including a diuretic): Consider adding a mineralocorticoid receptor antagonist (spironolactone) 1, 3

Blood Pressure Targets

• General target: <130/80 mmHg for most adults 1
• Older adults (≥65 years): Systolic BP target range of 130-139 mmHg 1, 3
• Patients with diabetes or CKD: Systolic BP target range of 130-139 mmHg 1

Common Pitfalls to Avoid

• Inadequate dosing: Many patients require multiple medications to achieve BP control 6
• Inappropriate combinations: Avoid combining ACE inhibitors with ARBs or direct renin inhibitors 1
• Ignoring lifestyle modifications: Continue lifestyle interventions even after starting medications 2, 7
• Overlooking secondary causes: Consider screening for secondary hypertension in resistant cases 1
• Neglecting home BP monitoring: Encourage home monitoring to assess treatment efficacy and improve adherence 3

Special Considerations

• Diabetes: ACE inhibitors or ARBs are preferred first-line agents 1
• Chronic kidney disease: ACE inhibitor or ARB recommended, especially with albuminuria 1
• Heart failure: Treatment should include ACE inhibitor/ARB, beta-blocker, and diuretic/MRA 1
• Resistant hypertension: Add spironolactone to existing treatment 1, 3

The most recent evidence strongly supports a comprehensive approach that combines lifestyle modifications with appropriate pharmacological therapy tailored to the patient's specific characteristics and comorbidities to effectively manage hypertension and reduce cardiovascular risk.