What are the recommended initial treatments for managing hypertension?

Initial Treatments for Managing Hypertension

The recommended initial treatment for hypertension should include lifestyle modifications for all patients, with first-line pharmacological therapy consisting of ACE inhibitors, ARBs, calcium channel blockers, or thiazide/thiazide-like diuretics, with combination therapy recommended for stage 2 hypertension or when BP is >20/10 mmHg above target. 1

Blood Pressure Classification and Treatment Thresholds

Blood pressure is classified as follows:

• 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

Treatment decisions should be based on:

1. BP level
2. Cardiovascular risk assessment
3. Presence of target organ damage or comorbidities

Lifestyle Modifications

Lifestyle modifications are essential first-line interventions for all hypertensive patients and should include:

• Weight reduction: Aim for ideal body weight; expect ~1 mmHg SBP reduction per 1 kg weight loss 1, 2
• Dietary modifications:
  • Sodium restriction (<1500 mg/day): 1-3 mmHg reduction per 1000 mg sodium reduction 1
  • DASH diet: ~5 mmHg SBP reduction 1
  • Increased potassium intake 2
  • Reduced alcohol consumption (<21 units/week for men, <14 units/week for women) 3, 2
• Physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise 1, 2
• Smoking cessation 2, 4

Even when pharmacological therapy is initiated, lifestyle modifications should be continued as they enhance medication efficacy and may reduce the number and doses of medications required 4.

Pharmacological Therapy

When to Initiate Drug Treatment

• Immediate drug treatment is recommended for:

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

• Delayed drug treatment (after lifestyle modifications for several weeks to months):

  • Grade 1 hypertension (140-159/90-99 mmHg) without high cardiovascular risk 3

First-Line Medication Options

The following are recommended as first-line antihypertensive agents:

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

   • Initial dose: One capsule daily 5
   • Maximum recommended dose: 50 mg daily 5

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

   • Initial dose: 10 mg once daily 6
   • Usual dosage range: 20-40 mg daily 6
   • Lower starting dose (5 mg) when used with diuretics 6

3. Angiotensin II receptor blockers (ARBs)

4. Calcium channel blockers (CCBs) 1, 7, 8

Combination Therapy

• For stage 2 hypertension (≥140/90 mmHg) or BP >20/10 mmHg above target, start with combination therapy using two first-line agents 1
• Preferred combinations:
  • ACE inhibitor or ARB + calcium channel blocker
  • ACE inhibitor or ARB + thiazide-like diuretic 1
• Fixed-dose combinations improve adherence 1

Special Population Considerations

• Black patients: Initial treatment should include a diuretic or CCB, either alone or with a RAS blocker 3, 1
• Diabetes: Include an ACE inhibitor or ARB in the regimen 1
• Chronic kidney disease: ACE inhibitor or ARB recommended, especially with albuminuria 3, 1
• Elderly patients (≥65 years): Target diastolic BP <80 mmHg with systolic 130-139 mmHg 1

Blood Pressure Targets

• General target: <130/80 mmHg 7
• For adults ≥65 years: SBP <130 mmHg 7
• The European Society of Cardiology recommends a target range of 120-129/70-79 mmHg if tolerated 3, 1

Monitoring and Follow-up

• Regular monitoring of blood pressure, renal function, and electrolytes is recommended
• Home blood pressure monitoring should be encouraged to guide treatment adjustments 1
• Allow 2-4 weeks to evaluate the full effect of medication dose adjustments 1

Common Pitfalls to Avoid

1. Inadequate initial assessment: Failure to accurately measure BP using validated devices with appropriate cuff size
2. Monotherapy for severe hypertension: Using single-agent therapy for stage 2 hypertension when combination therapy is more effective
3. Ignoring lifestyle modifications: Not emphasizing or following up on non-pharmacological interventions
4. Inappropriate drug selection: Not considering patient characteristics (age, race, comorbidities) when selecting medications
5. Therapeutic inertia: Failure to intensify treatment when BP remains uncontrolled

The most recent guidelines emphasize the importance of early and effective BP control to reduce cardiovascular morbidity and mortality, with evidence showing that a 10 mmHg reduction in SBP decreases risk of cardiovascular events by approximately 20-30% 7.