What is the recommended initial treatment for a patient with newly diagnosed hypertension?

Initial Treatment for Newly Diagnosed Hypertension

For patients with newly diagnosed hypertension, first-line pharmacological therapy should include a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), or a dihydropyridine calcium channel blocker (CCB), with the specific choice guided by patient characteristics and comorbidities. 1, 2, 3

Step 1: Lifestyle Modifications

Lifestyle modifications should be prescribed for all patients with hypertension, regardless of whether pharmacological therapy is initiated:

• Dietary changes:

  • Sodium restriction to <1500 mg/day or at least 1000 mg/day reduction 1, 2
  • Increased dietary potassium (3500-5000 mg/day) 1
  • DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy products 1, 2, 4

• Physical activity:

  • 90-150 minutes/week of aerobic or dynamic resistance exercise 1, 2
  • Alternatively, isometric resistance 3 sessions/week 1

• Other modifications:

  • Weight loss if overweight/obese 1, 2
  • Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) 1, 2

Step 2: Pharmacological Therapy Decision

When to Start Medications

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

  • Start medications if patient has:
    • Clinical cardiovascular disease
    • Diabetes mellitus
    • Chronic kidney disease
    • 10-year atherosclerotic cardiovascular disease risk ≥10%
  • Otherwise, begin with lifestyle modifications alone and reassess in 3-6 months 1

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

  • Start medications along with lifestyle modifications 1, 3
  • For BP ≥160/100 mmHg, consider initiating with two antihypertensive medications 1

First-Line Medication Selection

Choose from one of these first-line agents based on patient characteristics:

1. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)

   • Particularly effective in patients of African descent 2
   • Starting dose for hydrochlorothiazide: 12.5-25 mg daily

2. ACE inhibitors (e.g., lisinopril)

   • Starting dose: 10 mg once daily, usual range 20-40 mg daily 5
   • Preferred in patients with diabetes with albuminuria, chronic kidney disease, or heart failure 1
   • Avoid in pregnancy

3. ARBs (e.g., losartan)

   • Starting dose: 50 mg once daily, maximum 100 mg daily 6
   • Alternative to ACEIs if not tolerated (e.g., cough)
   • Preferred in patients with atrial fibrillation 1
   • Avoid in pregnancy

4. Dihydropyridine calcium channel blockers (e.g., amlodipine)

   • Particularly effective in patients of African descent 2
   • Can be used in pregnancy (nifedipine specifically)

Special Population Considerations

• Coronary artery disease: ACEIs or ARBs recommended as first-line therapy 1
• Chronic kidney disease: ACEIs or ARBs preferred 1
• Diabetes with albuminuria: ACEIs or ARBs preferred 1
• African descent patients: Consider thiazide diuretic or CCB as initial therapy 2
• Pregnancy: Avoid ACEIs and ARBs; methyldopa, labetalol, and nifedipine are preferred 2

Step 3: Monitoring and Follow-up

• Follow up approximately monthly for drug titration until BP is controlled 1
• Check electrolytes and renal function 2-4 weeks after initiating therapy, especially with diuretics, ACEIs, or ARBs 2
• Once BP is controlled, follow up every 3-6 months 2
• Consider home BP monitoring to guide treatment adjustments 2

Treatment Escalation

If BP remains uncontrolled on monotherapy:

1. Increase the dose of the initial agent to maximum tolerated dose
2. Add a second agent from a different class (typically combining an ACEI/ARB with either a thiazide diuretic or CCB)
3. Add a third agent if needed (typically an ACEI/ARB + thiazide diuretic + CCB)

Common Pitfalls to Avoid

• Inadequate dosing: Ensure medications are titrated to effective doses before adding new agents
• Medication non-adherence: Discuss potential side effects and importance of consistent medication use
• Ignoring lifestyle factors: Continuing lifestyle modifications is essential even after starting medications 4
• White coat hypertension: Consider home or ambulatory BP monitoring to confirm diagnosis 1
• Overlooking secondary causes: Consider screening for secondary hypertension in resistant cases 1

By following this algorithmic approach, most patients with newly diagnosed hypertension can achieve adequate blood pressure control, reducing their risk of cardiovascular events and mortality.