What are the treatment options for hypertension?

Treatment Options for Hypertension

The first-line treatment for hypertension should include lifestyle modifications along with pharmacological therapy using thiazide diuretics, ACE inhibitors/ARBs, or calcium channel blockers, with a target blood pressure of <130/80 mmHg for most adults. 1, 2

First-Line Pharmacological Options

• Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)
• ACE inhibitors (e.g., lisinopril) or ARBs (e.g., candesartan)
• Calcium channel blockers (e.g., amlodipine)

Lisinopril, an ACE inhibitor, is specifically indicated for the treatment of hypertension in adults and pediatric patients 6 years and older. It works by lowering blood pressure, which reduces the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions. 3

Step-by-Step Treatment Algorithm

1. Initiate with lifestyle modifications for all patients
2. Start pharmacological therapy based on blood pressure level and cardiovascular risk:
   • For most patients, begin with a single agent from one of the first-line classes
   • For BP significantly above target (>20/10 mmHg), consider initiating with two agents
3. Titrate medication dose based on office and home BP measurements
4. Add additional agents if BP remains uncontrolled:
   • If on metoprolol, add a thiazide diuretic, then an ACE inhibitor/ARB, then a calcium channel blocker 1
   • When combining beta-blockers with calcium channel blockers, prefer dihydropyridine CCBs 1
5. For resistant hypertension (BP ≥130/80 mmHg despite 3+ medications), consider:
   • Adding spironolactone 25-50mg daily, especially as a fourth-line agent 1
   • Referral to specialist for evaluation of secondary causes 1

Essential Lifestyle Modifications

• Sodium restriction to 2.3 g/day or less 1, 4, 5
• DASH diet high in fruits, vegetables, low-fat dairy, and low in red meat and fats 1, 2, 5
• Weight loss targeting BMI of 20-25 kg/m² 1, 4
• Physical activity 1, 4, 6
• Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) 1, 4, 6
• Potassium supplementation (unless contraindicated) 5, 6

Target Blood Pressure Goals

• Most adults: <130/80 mmHg 1, 2
• Adults ≥65 years: 130-139 mmHg systolic, <130 mmHg if tolerated 1
• High-risk patients (diabetes, CKD, cardiovascular disease): <130/80 mmHg 1

Special Population Considerations

• Heart failure patients: Consider adding spironolactone (25-100 mg daily) 1
• Benign prostatic hyperplasia: Alpha-1 blockers may be considered as second-line agents 1
• Diabetes, CKD, or heart failure: ACE inhibitors or ARBs are particularly beneficial 1, 3
• Black patients: May have smaller BP response to certain monotherapies 3

Important Monitoring and Precautions

• Monitor for orthostatic hypotension before and after initiating therapy 1
• Check serum creatinine/eGFR and potassium 1-4 weeks after starting ACE inhibitor/ARB therapy 1
• Avoid certain combinations:
  • ACE inhibitor + ARB
  • ACE inhibitor or ARB + direct renin inhibitor
  • Multiple beta-blockers simultaneously 1

Common Pitfalls to Avoid

• Inadequate dosing: Ensure optimal dosing before adding additional agents (e.g., metoprolol 50-200 mg daily for succinate form) 1
• Poor medication adherence: Often mistaken for true resistant hypertension 1
• Ignoring lifestyle factors: Dietary sodium restriction is critical for optimizing medication efficacy 1
• Overlooking secondary causes: Consider referral for evaluation when appropriate 1
• Neglecting home BP monitoring: Essential for confirming diagnosis and monitoring treatment 1

Many patients will require more than one drug to achieve blood pressure goals, and the selection of therapy should be guided by the patient's specific characteristics and comorbidities. 3, 2, 7