What are the recommended initial treatments for managing hypertension?

Initial Treatments for Managing Hypertension

The recommended initial treatment for hypertension should include a combination of lifestyle modifications and, for Stage 2 hypertension, immediate initiation of combination antihypertensive therapy with a thiazide-like diuretic plus a calcium channel blocker. 1

Diagnosis and Classification

• Blood pressure categories according to ACC/AHA:
  • Normal BP: <120/<80 mmHg
  • Elevated BP: 120-129/<80 mmHg
  • Stage 1 Hypertension: 130-139/80-89 mmHg
  • Stage 2 Hypertension: ≥140/≥90 mmHg 1

Lifestyle Modifications

Lifestyle modifications are essential first-line interventions for all patients with hypertension:

• Diet:

  • DASH diet (fruits, vegetables, whole grains, low-fat dairy, reduced saturated fat)
  • Sodium restriction (<2.3g/day)
  • Increased dietary potassium (3500-5000 mg/day) 1

• Physical Activity:

  • 150 minutes/week of moderate aerobic activity (30-60 minutes, 5-7 times weekly) 1

• Weight Management:

  • Target ideal body weight
  • Expect ~1 mmHg SBP reduction per 1 kg weight loss 1

• Alcohol Moderation:

  • ≤1 standard drink/day for women
  • ≤2 standard drinks/day for men 1

Pharmacological Treatment

Initial Drug Therapy Based on Hypertension Severity:

1. Stage 1 Hypertension (130-139/80-89 mmHg):

   • Start with lifestyle modifications for several weeks
   • If BP remains uncontrolled, initiate drug treatment 2, 1

2. Stage 2 Hypertension (≥140/≥90 mmHg):

   • Immediate initiation of drug treatment alongside lifestyle modifications 2, 1
   • First-line combination therapy: Thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) plus a long-acting calcium channel blocker (amlodipine) 1
   • Alternative first-line options: ARB or ACEI plus a calcium channel blocker 1

3. Severe Hypertension (≥180/≥110 mmHg):

   • Immediate drug treatment
   • Consider immediate hospitalization if signs of hypertensive emergency are present 1

Medication Dosing:

• Thiazide Diuretics: Initial dose of hydrochlorothiazide is one capsule once daily; total daily doses >50 mg not recommended 3
• ACE Inhibitors: For lisinopril, recommended initial dose is 10 mg once daily, with usual dosage range of 20-40 mg per day 4
• If BP is not controlled with ACE inhibitor alone, a low dose diuretic may be added (e.g., hydrochlorothiazide 12.5 mg) 4

Special Populations

• Black Patients:

  • Initial treatment should include a diuretic or CCB, either alone or with a RAS blocker
  • ARBs may be preferred over ACEIs due to lower risk of angioedema 1

• Elderly Patients:

  • Start with lower doses and titrate more gradually
  • Individualize BP targets based on frailty 1

• Chronic Kidney Disease:

  • Consider loop diuretics instead of thiazides if creatinine clearance <30 mL/min 1
  • RAS blockers are recommended for patients with albuminuria or proteinuria 2

Monitoring and Follow-up

• Monthly visits until BP target is achieved, then every 3-6 months
• Monitor electrolytes and renal function 2-4 weeks after initiating therapy, especially with diuretics or ACE inhibitors
• Home BP monitoring is recommended to guide treatment adjustments 1

Management of Resistant Hypertension

If BP remains uncontrolled on optimal doses of 3 medications (including a diuretic):

• Add spironolactone (mineralocorticoid receptor antagonist)
• If spironolactone is not effective or tolerated, consider eplerenone, beta-blockers, or other agents 2, 1

Treatment Targets

• For most adults: <130/80 mmHg
• For elderly patients: SBP <130 mmHg if tolerated
• For patients with CKD (eGFR >30 mL/min/1.73m²): SBP 120-129 mmHg 2, 5

The evidence clearly demonstrates that effective BP control significantly reduces cardiovascular morbidity and mortality, with an SBP reduction of 10 mmHg decreasing risk of CVD events by approximately 20-30% 5.