What are the recommended initial treatments for managing hypertension?

Initial Treatment for Hypertension Management

The recommended initial treatment for hypertension should include lifestyle modifications for all patients, followed by pharmacological therapy with a thiazide/thiazide-like diuretic, angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), or calcium channel blocker (CCB) as first-line medications based on patient characteristics. 1, 2

Blood Pressure Classification and Treatment Thresholds

Category	Systolic BP	Diastolic BP	Initial Approach
Normal BP	<120 mmHg	<80 mmHg	Lifestyle modifications
Elevated BP	120-129 mmHg	<80 mmHg	Lifestyle modifications
Stage 1 Hypertension	130-139 mmHg	80-89 mmHg	Lifestyle + consider medications
Stage 2 Hypertension	≥140 mmHg	≥90 mmHg	Lifestyle + medications

Step 1: Lifestyle Modifications (For All Patients)

Lifestyle modifications are the cornerstone of hypertension management and should be implemented for all patients 1, 3:

• Weight reduction: Achieve ideal body weight through reduced caloric intake
• Dietary approach: DASH or Mediterranean diet
• Sodium restriction: <2.3g/day
• Increased potassium intake: Through fruits and vegetables
• Physical activity: At least 150 minutes/week of moderate aerobic activity
• Alcohol limitation: <21 units/week for men, <14 units/week for women
• Smoking cessation: Complete cessation

Step 2: Pharmacological Therapy

When to Initiate Medications:

• Immediate drug treatment for:

  • Grade 2-3 hypertension (≥160/100 mmHg)
  • Patients with established cardiovascular or renal disease
  • Patients with diabetes 4

• Lifestyle changes for several weeks then drug treatment if BP uncontrolled for:

  • Grade 1 hypertension (140-159/90-99 mmHg) with 1-2 risk factors 4

First-Line Medication Options:

1. Thiazide or thiazide-like diuretics:

   • Example: Hydrochlorothiazide starting at 12.5-25mg once daily 5
   • Particularly effective in black patients and elderly

2. ACE inhibitors or ARBs:

   • Example: Lisinopril starting at 10mg once daily 6
   • Preferred in patients with diabetes, chronic kidney disease, or heart failure
   • Not recommended as first-line in black patients unless combined with a CCB or diuretic

3. Calcium channel blockers:

   • Example: Amlodipine starting at 5mg once daily
   • Effective in all patient populations, particularly black patients

Special Population Considerations:

• Black patients: Initial therapy should include a diuretic or CCB, either alone or in combination with a RAS blocker 4, 1

• Patients with albuminuria/proteinuria: ACE inhibitors or ARBs are recommended 4, 1

• Elderly patients: Start with lower doses and titrate more gradually 1

• Chronic kidney disease: ACE inhibitors or ARBs are preferred; consider loop diuretics instead of thiazides if eGFR <30 mL/min 1

Step 3: Combination Therapy

If blood pressure remains uncontrolled on monotherapy:

1. Add a second agent from a different class (typically combining a RAS blocker with either a CCB or diuretic)

2. For resistant hypertension (uncontrolled on ≥3 agents including a diuretic):

   • Add spironolactone 25mg daily if potassium <4.5 mmol/L and eGFR >45 mL/min/1.73m²
   • Alternatives: eplerenone, amiloride, higher dose thiazide/thiazide-like diuretic, loop diuretic, bisoprolol, or doxazosin 4

Blood Pressure Targets

• General population: <130/80 mmHg for adults <65 years; SBP <130 mmHg for adults ≥65 years 2
• Minimum acceptable control: <150/90 mmHg 4
• CKD patients with eGFR >30 mL/min/1.73m²: 120-129 mmHg systolic 4
• Stroke/TIA patients: 120-130 mmHg systolic 4

Monitoring and Follow-up

• Monitor BP frequently until controlled
• Follow up monthly until BP is controlled, then every 3-6 months
• Check laboratory tests (creatinine, potassium) 7-14 days after starting or modifying treatment with ACE inhibitors, ARBs, or diuretics 1

Common Pitfalls to Avoid

1. Neglecting lifestyle modifications when initiating drug therapy
2. Inadequate dosing or failing to titrate medications appropriately
3. Not considering combination therapy when monotherapy is insufficient
4. Overlooking medication adherence issues in patients with uncontrolled BP
5. Excessive BP lowering in elderly patients (avoid diastolic BP <70-75 mmHg in those with coronary heart disease) 1

By following this structured approach to hypertension management, clinicians can effectively reduce cardiovascular morbidity and mortality in patients with elevated blood pressure.