What are the recommended initial treatments for managing hypertension?

Initial Treatment Recommendations for Hypertension Management

First-line pharmacological therapy for hypertension 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 lifestyle modifications prescribed for all patients regardless of whether medication is initiated. 1

When to Initiate Antihypertensive Treatment

The decision to start medication depends on blood pressure levels and cardiovascular risk:

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

  • Start medications if patient has clinical cardiovascular disease, diabetes mellitus, chronic kidney disease, or 10-year atherosclerotic cardiovascular disease risk ≥10% 1
  • Otherwise, begin with lifestyle modifications for several months 2

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

  • Start medications along with lifestyle modifications 1
  • For BP ≥160/100 mmHg, consider initiating with two antihypertensive medications 1
  • For Grade 3 hypertension (≥180/110 mmHg), immediate drug treatment is recommended 2

Lifestyle Modifications (Essential for All Patients)

All patients with hypertension should receive these interventions:

• Dietary changes:

  • Sodium restriction to <1500 mg/day (expected 1-3 mmHg SBP reduction per 1000 mg sodium reduction) 1
  • Increased dietary potassium (3500-5000 mg/day) through fruits and vegetables 1
  • DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy products (reduces SBP by ~5 mmHg) 1

• Physical activity:

  • 90-150 minutes/week of aerobic or dynamic resistance exercise 1

• Weight management:

  • Weight loss if overweight/obese (expected ~1 mmHg SBP reduction per 1 kg weight loss) 1

• Alcohol moderation:

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

• Smoking cessation 3

First-Line Pharmacological Options

The 2024 guidelines recommend the following first-line medications:

1. Thiazide or thiazide-like diuretics:

   • Example: Hydrochlorothiazide, initial dose 12.5-25 mg once daily 4
   • Particularly effective in Black patients 1

2. ACE inhibitors or ARBs:

   • Example: Lisinopril, initial dose 10 mg once daily, usual range 20-40 mg daily 5
   • Preferred for patients with diabetes with albuminuria, chronic kidney disease, or heart failure 1
   • ARBs preferred over ACEIs in Black patients due to lower risk of angioedema 1

3. Dihydropyridine calcium channel blockers:

   • Example: Amlodipine
   • Particularly effective in Black patients when combined with thiazide diuretics 1

Special Population Considerations

• Black patients: Initial therapy should include a diuretic or CCB, either alone or in combination with a RAS blocker 2

• Diabetes: Include an ACE inhibitor or ARB in the regimen 1

• Chronic kidney disease: ACE inhibitor or ARB recommended as part of treatment 1

• Elderly patients (≥65 years): Target diastolic BP <80 mmHg with systolic 130-139 mmHg 1

Combination Therapy Approach

• 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
  3. Add a third agent if needed 1

• For BP ≥160/100 mmHg, consider initiating with two antihypertensive medications 1

• When using diuretics with ACE inhibitors:

  • If blood pressure is not controlled with lisinopril alone, add a low dose diuretic (e.g., hydrochlorothiazide 12.5 mg)
  • After adding a diuretic, it may be possible to reduce the dose of lisinopril 5

Follow-up and Monitoring

• Follow up approximately monthly for drug titration until BP is controlled
• Consider home BP monitoring to guide treatment adjustments
• Target blood pressure should be <130/80 mmHg for most patients 1

Common Pitfalls to Avoid

• Overlooking secondary causes of hypertension in resistant cases
• Inadequate dosing or medication non-adherence
• Ignoring lifestyle factors when prescribing medications
• White coat hypertension (consider home or ambulatory BP monitoring to confirm diagnosis)
• Not accounting for patient characteristics (age, ethnicity, comorbidities) when selecting medications

Remember that an SBP reduction of 10 mmHg decreases risk of cardiovascular disease events by approximately 20% to 30% 6, highlighting the importance of effective hypertension management.