What is the initial treatment for Stage 2 Hypertension (HTN)?

Initial Treatment for Stage 2 Hypertension

For stage 2 hypertension (≥140/90 mmHg), treatment should begin with a combination of two antihypertensive medications from different classes along with lifestyle modifications. 1, 2

Pharmacological Treatment

First-line Combination Therapy

• Start with a two-drug combination from the following classes:

  • ACE inhibitor or ARB plus either:
    • Thiazide-like diuretic (preferred: chlorthalidone or indapamide) OR
    • Calcium channel blocker (dihydropyridine type)

• Specific recommended combinations:

  1. ACE inhibitor (e.g., lisinopril) + thiazide-like diuretic (e.g., chlorthalidone)
  2. ARB + thiazide-like diuretic
  3. ACE inhibitor + calcium channel blocker
  4. ARB + calcium channel blocker

Dosing Considerations

• For initial therapy with lisinopril: Start with 10 mg once daily, titrate to 20-40 mg daily as needed 3
• For chlorthalidone: Start with 25 mg once daily, may increase to 50 mg if needed 4
• Allow 2-4 weeks to observe full response before making dose adjustments 2

Special Population Considerations

• African American patients: Consider starting with calcium channel blocker + thiazide diuretic 2
• Patients with albuminuria (UACR ≥30 mg/g): Use ACE inhibitor or ARB as one of the agents 1
• Patients with coronary artery disease: Include ACE inhibitor or ARB 1
• Women of childbearing potential: Avoid ACE inhibitors and ARBs due to teratogenicity 1, 2

Lifestyle Modifications (Implement Concurrently)

All patients with stage 2 hypertension should receive counseling on lifestyle modifications:

• DASH-style eating pattern: Emphasize fruits, vegetables, low-fat dairy (3-11 mmHg reduction) 1, 2
• Sodium restriction: <2,300 mg/day (3-6 mmHg reduction) 1, 2
• Physical activity: At least 150 minutes of moderate-intensity exercise weekly (3-8 mmHg reduction) 1, 2
• Weight management: For those overweight/obese, aim for 1 mmHg reduction per kg lost 2
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women (3-4 mmHg reduction) 1, 2
• Smoking cessation 1

Monitoring and Follow-up

• Evaluate patients within 1 month of initiating treatment 1, 2
• Check electrolytes and renal function 2-4 weeks after starting ACE inhibitors, ARBs, or diuretics 1
• Monitor BP every 2-4 weeks until goal is achieved, then every 3-6 months 2
• Target BP goal: <130/80 mmHg for most patients 1, 2

Common Pitfalls to Avoid

1. Clinical inertia: Don't delay intensification of therapy when BP remains uncontrolled
2. Monotherapy: Starting with a single agent is insufficient for stage 2 hypertension
3. Inappropriate combinations: Avoid combining two RAS blockers (ACE inhibitor + ARB) 2
4. Overlooking interfering substances: NSAIDs, stimulants, and certain medications can worsen hypertension 2
5. Ignoring adherence issues: Simplify regimen with once-daily dosing when possible 2
6. Inadequate lifestyle counseling: Lifestyle modifications enhance medication efficacy 5

By implementing this comprehensive approach of dual-agent pharmacotherapy plus lifestyle modifications, you can effectively manage stage 2 hypertension and reduce the risk of cardiovascular events and mortality.