What is the initial approach to starting antihypertensive (blood pressure lowering) medication in patients with hypertension (high blood pressure)?

Initial Approach to Starting Antihypertensive Medication

For patients with hypertension, initial antihypertensive therapy should be based on blood pressure severity, with monotherapy for stage 1 hypertension and combination therapy for stage 2 hypertension or BP >20/10 mmHg above target. 1

Assessment of Hypertension Severity

• Confirm hypertension diagnosis with office BP ≥140/90 mmHg or home BP ≥135/85 mmHg or 24h ambulatory BP ≥130/80 mmHg 1
• Classify hypertension:
  • Grade 1/Stage 1: 140-159/90-99 mmHg
  • Grade 2/Stage 2: ≥160/100 mmHg

Initial Treatment Algorithm

Step 1: Lifestyle Modifications (for all patients)

• Sodium restriction (<1500 mg/day)
• Increased potassium intake (3500-5000 mg/day)
• Weight loss if overweight/obese
• Physical activity (90-150 min/week)
• Moderation of alcohol intake
• DASH diet (fruits, vegetables, whole grains, low-fat dairy) 1

Step 2: Pharmacological Therapy Based on BP Level

For Stage 1 Hypertension (140-159/90-99 mmHg):

• High-risk patients (CVD, CKD, diabetes, organ damage, or age 50-80): Start drug therapy immediately
• Low-risk patients: Trial of lifestyle modifications for 3-6 months, then start drug if BP remains elevated 1
• Initial drug choice: Single agent (monotherapy) 1

For Stage 2 Hypertension (≥160/100 mmHg) or BP >20/10 mmHg above target:

• Start drug therapy immediately alongside lifestyle modifications
• Initial drug choice: Two-drug combination therapy 1

Drug Selection Based on Patient Demographics

For Non-Black Patients:

1. Start with low-dose ACE inhibitor (e.g., lisinopril 10 mg daily) 2 or ARB (e.g., losartan 50 mg daily) 3
2. If BP not controlled, increase to full dose
3. Add thiazide/thiazide-like diuretic (e.g., chlorthalidone 25 mg daily) 4
4. If needed, add calcium channel blocker 1

For Black Patients:

1. Start with low-dose ARB (e.g., losartan 50 mg daily) 3
2. Add dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic
3. Increase to full doses
4. Add ACE inhibitor if needed 1

Special Considerations

• Elderly patients (>80 years) or frail: Consider monotherapy at lower starting doses with more gradual titration 1
• Patients with comorbidities: Drug selection should be tailored:
  • Diabetes with albuminuria: Prefer ACE inhibitor or ARB
  • Chronic kidney disease: Prefer ACE inhibitor or ARB
  • Heart failure: Prefer ACE inhibitor/ARB, beta-blocker, and diuretic 1

Monitoring and Follow-up

• Monitor BP control within 3 months of starting therapy
• Target: Reduce BP by at least 20/10 mmHg; ideally to <140/90 mmHg
• Check electrolytes and renal function after starting ACE inhibitors, ARBs, or diuretics 1

Common Pitfalls to Avoid

• Therapeutic inertia: Failure to intensify treatment when BP remains uncontrolled
• Rapid BP reduction: Avoid excessive lowering in elderly patients, which may lead to orthostatic hypotension
• Inappropriate drug combinations: Avoid combining ACE inhibitors with ARBs
• Inadequate dosing: Ensure adequate dosing before adding additional agents 5

The evidence strongly supports a stepped-care approach for most patients, with initial monotherapy for stage 1 hypertension and combination therapy for stage 2 hypertension. This approach balances efficacy with minimizing side effects, which is crucial for long-term adherence and successful BP control.