What is the initial approach to treating hypertension?

Initial Approach to Treating Hypertension

The initial approach to treating hypertension should begin with lifestyle modifications for all patients, followed by combination pharmacological therapy with a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1, 2

Step 1: Lifestyle Modifications

Lifestyle modifications are the foundation of hypertension management and should be implemented for all patients:

• Weight management: Achieve and maintain healthy body mass index 1, 2
• DASH diet: High in fruits, vegetables, low-fat dairy; low in red meat and fats 1, 2
• Sodium restriction: ≤2.3 g/day 2
• Physical activity: Regular exercise within patient's limitations 1, 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• Smoking cessation 2

These modifications can lower BP by 5-10 mmHg and enhance the efficacy of pharmacological therapy 3.

Step 2: Pharmacological Therapy

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

• Start with a single antihypertensive medication and adjust dose 2
• Monitor response and add additional agents sequentially to achieve BP goal

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

• Initiate with combination therapy using two first-line agents from different classes 1, 2
• Preferred combinations: RAS blocker (ACE inhibitor or ARB) with either:
  • Dihydropyridine calcium channel blocker (e.g., amlodipine)
  • Thiazide/thiazide-like diuretic (e.g., chlorthalidone, hydrochlorothiazide)
• Use fixed-dose single-pill combinations when possible to improve adherence 1

First-line Medication Classes:

1. ACE inhibitors (e.g., lisinopril): Starting dose 10 mg daily 4
2. ARBs (e.g., losartan)
3. Calcium channel blockers (dihydropyridines like amlodipine)
4. Thiazide/thiazide-like diuretics (e.g., chlorthalidone): Starting dose 25 mg daily 5

Step 3: Titration and Optimization

• If BP not controlled with a two-drug combination, advance to a three-drug combination: RAS blocker + calcium channel blocker + thiazide diuretic 1
• If BP remains uncontrolled, consider adding spironolactone as a fourth agent 1, 2
• Aim to achieve BP control within 3 months to maintain patient confidence and ensure long-term adherence 1

Special Population Considerations

• African American patients: Thiazide diuretics and calcium channel blockers are more effective as first-line agents 2
• Patients with diabetes or CKD: ACE inhibitors or ARBs preferred 2
• Patients with heart failure: ACE inhibitors/ARBs and specific beta-blockers indicated 2
• Elderly patients (≥65 years): Start with lower doses and titrate more gradually 2
• Very elderly (≥80 years): Consider BP target of 140-150/<80 mmHg 2

Monitoring and Follow-up

• Check BP control and adverse effects 4-12 weeks after treatment initiation 2
• Monitor serum potassium and renal function within 3 months of starting ACE inhibitors, ARBs, or diuretics 2
• Assess medication adherence if BP targets not achieved 2
• Consider home BP monitoring to guide therapy adjustments 1

Treatment Targets

• General population: <130/80 mmHg 2
• Age 65-79 years: 130-139/80 mmHg 2
• Age ≥80 years: 140-150/<80 mmHg 2

The evidence clearly shows that prompt and effective BP control significantly reduces cardiovascular morbidity and mortality 1, 3. An SBP reduction of 10 mmHg decreases risk of cardiovascular events by approximately 20-30% 3.