What is the main treatment for hypertension?

Main Treatment for Hypertension

The main treatment for hypertension includes both lifestyle modifications and pharmacological therapy with first-line medications including thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, and calcium channel blockers. 1, 2

Lifestyle Modifications

Lifestyle modifications form the foundation of hypertension treatment and should be implemented for all patients:

• Weight loss: 5-20 mmHg reduction per 10 kg lost 1
• DASH diet: Rich in fruits, vegetables, and low-fat dairy products; 8-14 mmHg reduction 2, 1
• Sodium restriction: <2,300 mg/day; 2-8 mmHg reduction 2, 1
• Physical activity: 150 minutes/week of moderate activity; 4-9 mmHg reduction 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women; 2-4 mmHg reduction 2, 1

These lifestyle interventions are particularly important for individuals with mildly elevated blood pressure (systolic ≥120 mmHg or diastolic ≥80 mmHg) and should be initiated alongside pharmacologic therapy when hypertension is diagnosed 2.

Pharmacological Therapy

When blood pressure remains elevated despite lifestyle modifications or in patients with higher initial blood pressure, pharmacological therapy is indicated:

First-Line Medications

1. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)
2. ACE inhibitors (e.g., lisinopril)
3. Angiotensin receptor blockers (ARBs) (e.g., losartan)
4. Calcium channel blockers (CCBs) (e.g., amlodipine)

Treatment Initiation Guidelines

• BP ≥140/90 mmHg: Prompt initiation of pharmacological therapy along with lifestyle modifications 2
• BP ≥160/100 mmHg: Immediate initiation of two drugs or a single-pill combination 2

Special Population Considerations

• Black patients: Calcium channel blocker or thiazide-like diuretic preferred as initial therapy 1
• Diabetes or CKD: ACE inhibitor or ARB preferred as initial therapy 1, 2
• Heart failure: ACE inhibitor/ARB, beta-blocker, mineralocorticoid receptor antagonist recommended 1, 2

Treatment Goals

• Target BP for most adults: <130/80 mmHg 1
• Target BP for elderly patients (≥65 years): 130-140/80 mmHg if tolerated 1, 2
• Target BP for diabetes or CKD: <130/80 mmHg 1

Combination Therapy

Many patients will require multiple medications to achieve blood pressure goals 3, 4. When monotherapy is insufficient:

• Consider two-drug combinations with complementary mechanisms (e.g., ACE inhibitor/ARB + diuretic) 2
• For resistant hypertension, adding spironolactone (25-50 mg/day) is often effective 1
• Avoid combining ACE inhibitors with ARBs or direct renin inhibitors due to increased risk of adverse effects 2

Monitoring and Follow-up

• Follow-up within 2-4 weeks for BP 140-159/90-99 mmHg and within 1-2 weeks for BP ≥160/100 mmHg 1
• Monitor serum creatinine, eGFR, and potassium within 2-4 weeks of starting ACE inhibitors, ARBs, or diuretics 1
• Home BP monitoring is recommended to guide medication titration 1

Common Pitfalls to Avoid

1. Inadequate dosing: Many patients remain on initial doses without appropriate titration
2. Clinical inertia: Failure to intensify treatment when BP goals are not met
3. Medication non-adherence: Address barriers such as cost, side effects, and complex regimens
4. Ignoring secondary causes: Consider screening for secondary hypertension in resistant cases
5. Overlooking lifestyle modifications: These remain essential even when medications are prescribed

The evidence clearly demonstrates that blood pressure reduction, rather than specific pharmacological properties of drugs, is primarily responsible for cardiovascular benefits 3, 4. Effective hypertension management significantly reduces the risk of stroke, myocardial infarction, heart failure, and mortality.