What is the first line treatment for a patient with newly diagnosed hypertension (HTN) and no comorbidities?

First-Line Treatment for Newly Diagnosed Hypertension with No Comorbidities

For a patient with newly diagnosed hypertension and no comorbidities, the first-line treatment should begin with lifestyle modifications, followed by pharmacological therapy with an ACE inhibitor/ARB (for non-Black patients) or a calcium channel blocker/thiazide diuretic (for Black patients) if blood pressure remains elevated. 1, 2

Initial Assessment and Classification

• Confirm hypertension diagnosis with:

  • Repeated office BP ≥140/90 mmHg
  • Home BP ≥135/85 mmHg or 24h ambulatory BP ≥130/80 mmHg 1

• Classify hypertension severity:

  • Grade 1: 140-159/90-99 mmHg
  • Grade 2: ≥160/100 mmHg 1

Treatment Algorithm

Step 1: Lifestyle Modifications

All patients with newly diagnosed hypertension should start lifestyle modifications immediately, which can reduce systolic BP by:

• Weight loss: 5-20 mmHg per 10 kg lost
• DASH diet: 8-14 mmHg
• Sodium reduction: 2-8 mmHg
• Physical activity (150 min/week): 4-9 mmHg
• Moderate alcohol consumption: 2-4 mmHg 2

Step 2: Pharmacological Therapy

For Grade 1 Hypertension (140-159/90-99 mmHg):

• Non-Black patients:

  • Start with low-dose ACE inhibitor (e.g., lisinopril) or ARB 1, 2
  • If BP not controlled, increase to full dose
  • If still not controlled, add thiazide/thiazide-like diuretic 1

• Black patients:

  • Start with low-dose ARB + dihydropyridine calcium channel blocker (DHP-CCB) or DHP-CCB + thiazide/thiazide-like diuretic 1
  • If BP not controlled, increase to full dose
  • If still not controlled, add diuretic or ACE inhibitor/ARB 1

For Grade 2 Hypertension (≥160/100 mmHg):

• Start drug treatment immediately along with lifestyle interventions
• Consider initial combination therapy, preferably as a single-pill combination 1, 3

Medication Selection Rationale

Lisinopril (ACE inhibitor) is particularly effective for:

• Lowering blood pressure through suppression of the renin-angiotensin-aldosterone system
• Reducing cardiovascular morbidity and mortality
• Providing 24-hour blood pressure control with once-daily dosing 4

Treatment Targets and Monitoring

• Target: Reduce BP by at least 20/10 mmHg; ideally to <130/80 mmHg 1, 2
• Achieve BP control within 3 months 1, 2
• Monitor serum creatinine, eGFR, and potassium within 2-4 weeks of starting ACE inhibitors, ARBs, or diuretics 2
• Schedule follow-up based on initial BP:
  • BP 140-159/90-99 mmHg: Follow-up within 2-4 weeks
  • BP ≥160/100 mmHg: Follow-up within 1-2 weeks 2

Important Considerations

• ACE inhibitors, ARBs, calcium channel blockers, and thiazide diuretics are all considered first-line options, but selection should be based on patient demographics and characteristics 5, 6
• Black patients typically have a smaller average response to ACE inhibitors/ARBs monotherapy compared to non-Black patients 4
• Simplify regimen with once-daily dosing to improve adherence 1
• If BP remains uncontrolled despite optimal therapy, refer to a specialist with hypertension expertise 1