What are the first line medications for hypertension?

First-Line Medications for Hypertension

The first-line medications for hypertension include thiazide diuretics, calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs). 1

Evidence-Based Recommendations

The 2017 ACC/AHA guidelines provide a Class I recommendation (highest level) for these four medication classes as initial therapy for hypertension:

• Thiazide diuretics (especially chlorthalidone)
• Calcium channel blockers (CCBs)
• ACE inhibitors
• ARBs

Medication Selection Algorithm

When selecting among first-line agents, consider the following factors:

1. Patient Demographics

• Black patients: Thiazide diuretics or CCBs are more effective as initial therapy 1
• Non-Black patients: Any of the four first-line classes can be used

2. Comorbid Conditions

• Chronic kidney disease: ACE inhibitors or ARBs preferred 1, 2
• Heart failure: ACE inhibitors, ARBs preferred 2
• Diabetes: ACE inhibitors or ARBs recommended as foundation of treatment 2

3. Comparative Effectiveness

• Thiazide diuretics: Superior in preventing heart failure compared to CCBs and ACE inhibitors 1
• CCBs: More effective than beta-blockers for stroke prevention 1
• ACE inhibitors: Effective for mortality reduction but less effective than thiazides and CCBs for BP lowering and stroke prevention in some populations 1

Important Clinical Considerations

Medication-Specific Notes

• Chlorthalidone (thiazide-like diuretic) has stronger evidence for cardiovascular outcomes than hydrochlorothiazide 1, 3
• ACE inhibitors may cause cough and angioedema, particularly in Black patients 1
• ARBs have similar efficacy to ACE inhibitors with fewer side effects like cough 1

Combination Therapy

• Most patients with stage 2 hypertension (BP ≥140/90 mmHg) will require multiple medications 1, 2
• Initial combination therapy is recommended for patients with BP >20/10 mmHg above target 1
• Do not combine ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 2

Monitoring

• Check renal function and electrolytes within 2-4 weeks of starting ACE inhibitors, ARBs, or diuretics 2
• Follow up within 1 month for medication adjustment if target BP is not achieved 2

Common Pitfalls to Avoid

1. Using beta-blockers as first-line therapy - Beta-blockers are less effective for stroke prevention and are no longer recommended as first-line unless there are specific indications (e.g., coronary artery disease) 1, 4

2. Using alpha-blockers as first-line therapy - Alpha-blockers are not recommended as initial therapy due to less favorable cardiovascular outcomes 1

3. Combining ACE inhibitors with ARBs - This combination increases risk of hyperkalemia and acute kidney injury without additional benefit 1, 2

4. Neglecting patient-specific factors - Medication choice should consider race, comorbidities, and potential side effects 1, 2

5. Inadequate dosing - Insufficient dosing is a common reason for treatment failure; proper titration is essential 2

By following these evidence-based recommendations and considering patient-specific factors, clinicians can optimize hypertension management to reduce cardiovascular morbidity and mortality.