What are the initial treatment recommendations for hypertension, including lifestyle modifications and medication options?

Hypertension Treatment Recommendations

Initial treatment of hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy with a thiazide-type diuretic, ACE inhibitor/ARB, or calcium channel blocker as first-line medication options, with specific drug choices based on patient characteristics. 1, 2

Hypertension Classification

Category	Systolic BP	Diastolic BP
Normal BP	<120 mmHg	<80 mmHg
Elevated BP	120-129 mmHg	<80 mmHg
Stage 1 Hypertension	130-139 mmHg	80-89 mmHg
Stage 2 Hypertension	≥140 mmHg	≥90 mmHg

Lifestyle Modifications (First-Line for All Patients)

Lifestyle modifications are essential for all patients with hypertension and should include:

• Dietary modifications:

  • DASH diet (emphasizing fruits, vegetables, low-fat dairy)
  • Sodium restriction (<2,300 mg/day)
  • Increased potassium intake
  • Limited alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women)

• Physical activity:

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

• Weight management:

  • Target BMI of 20-25 kg/m²
  • ~1 mmHg SBP reduction per 1 kg weight loss

• Smoking cessation 1, 3, 4, 5, 6

Pharmacological Treatment Algorithm

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

1. Start with a single antihypertensive drug
2. Target BP goal: <130/80 mmHg
3. Recommended first-line options (choose one):
   • Thiazide-type diuretic (preferably chlorthalidone)
   • ACE inhibitor (e.g., lisinopril)
   • ARB
   • Calcium channel blocker (e.g., amlodipine)

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

1. Initiate with two agents from different classes
2. Preferred combinations:
   • Thiazide diuretic + ACE inhibitor
   • Thiazide diuretic + ARB
   • Calcium channel blocker + ACE inhibitor
   • Calcium channel blocker + ARB 1, 2

Special Population Considerations

• Black patients:

  • First-line: Thiazide diuretic or calcium channel blocker
  • ARBs preferred over ACE inhibitors (lower risk of angioedema) 7, 1

• Patients with diabetes or albuminuria:

  • First-line: ACE inhibitor or ARB 1, 7

• Patients with chronic kidney disease:

  • Consider loop diuretic instead of thiazide if eGFR <30 mL/min 1

• Elderly patients (≥65 years):

  • Target BP: <130 mmHg if tolerated
  • For very elderly (>80 years): 140-145 mmHg if well tolerated 7, 1

Monitoring and Follow-up

• Confirm hypertension diagnosis with multiple readings on at least 2-3 separate visits
• Monitor blood pressure, renal function, and electrolytes regularly, particularly when adding or adjusting medications
• For patients on ACE inhibitors, ARBs, or diuretics: Check serum creatinine/eGFR and potassium levels at least annually
• Encourage home blood pressure monitoring to guide treatment adjustments
• Consider referral to a hypertension specialist if blood pressure remains elevated despite 6 months of treatment 1

Treatment Targets

• General population: <130/80 mmHg
• Older adults (≥65 years): <130 mmHg systolic if tolerated
• Very elderly (>80 years): 140-145 mmHg if well tolerated 1

Common Pitfalls and Caveats

• Inadequate lifestyle modification: Many patients require continued reinforcement of lifestyle changes even after starting medications
• Suboptimal medication choices: Not considering patient-specific factors when selecting antihypertensive agents
• Insufficient dosing: Failing to titrate medications to effective doses before adding new agents
• Poor medication adherence: Not addressing barriers to adherence such as cost, side effects, or complex regimens
• White coat hypertension: Not confirming office readings with home or ambulatory monitoring when suspected
• Resistant hypertension: Not considering secondary causes when BP remains elevated despite multiple medications 1, 2

By following this structured approach to hypertension management, clinicians can effectively reduce cardiovascular risk and improve patient outcomes through appropriate lifestyle modifications and evidence-based pharmacological therapy.