What is the first-line antihypertensive medication for a 58-year-old male with stage 1 hypertension (Blood Pressure 140/94 mmHg)?

From the Guidelines

For a 58-year-old male with stage 1 hypertension, a thiazide diuretic such as chlorthalidone 12.5-25 mg daily is the recommended first-line antihypertensive medication. This recommendation is based on the 2017 American College of Cardiology/American Heart Association hypertension guideline, which suggests that thiazide diuretics, calcium-channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers are suitable options for initial therapy in adults without a compelling indication for a specific drug 1. The guideline emphasizes the importance of blood pressure lowering above the choice of drug, and thiazide diuretics, especially chlorthalidone, are preferred options for first-line therapy in most U.S. adults due to their efficacy.

Some key points to consider when initiating antihypertensive therapy include:

• The recommended blood pressure target is less than 130/80 mm Hg, regardless of ASCVD risk 1
• Lifestyle modifications, such as sodium restriction, regular exercise, weight management, and limiting alcohol intake, should be implemented concurrently with medication
• The choice of antihypertensive medication should be individualized based on comorbidities, such as diabetes or chronic kidney disease, where an ACE inhibitor or ARB may be preferred
• Monitoring of electrolytes and kidney function is necessary when starting ACE inhibitors or ARBs, and should be done 1-2 weeks after initiation 1

Alternative options for first-line therapy include:

• Calcium channel blockers, such as amlodipine 5-10 mg daily
• ACE inhibitors, such as lisinopril 10-20 mg daily
• Angiotensin-receptor blockers, such as losartan 50-100 mg daily It is essential to start with the lower dose and titrate up after 2-4 weeks if blood pressure remains above target, and to monitor blood pressure regularly to assess the effectiveness of therapy 1.

From the FDA Drug Label

Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits

• The FDA drug label for lisinopril does not specify a first-line antihypertensive medication for a 58-year-old male with stage 1 hypertension.
• However, it does indicate that lisinopril is used to treat hypertension in adult patients.
• The label also mentions that many patients will require more than 1 drug to achieve blood pressure goals and refers to published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), for specific advice on goals and management 2. The FDA drug label does not answer the question.

From the Research

First-Line Antihypertensive Medication

The first-line antihypertensive medication for a 58-year-old male with stage 1 hypertension (Blood Pressure 140/94 mmHg) can be considered based on the provided evidence.

• The studies suggest that ACE inhibitors, such as lisinopril, are effective in lowering blood pressure and can be considered as a first-line agent for reducing blood pressure 3, 4.
• Lisinopril has been shown to be effective in elderly patients with hypertension, with a response rate of 68.2 to 89.1% in clinical trials 4.
• The use of lisinopril in patients with hypertension has been associated with a reduction in mortality and left ventricular dysfunction, particularly in elderly patients 4.
• Combination therapy with an ACE inhibitor and a calcium channel blocker may also be considered, as it has been shown to be well-tolerated and effective in reducing blood pressure 5, 6.

Considerations for Treatment

When considering treatment for this patient, the following factors should be taken into account:

• The patient's age and medical history, including the presence of any comorbid conditions such as diabetes or kidney disease 3, 4.
• The patient's blood pressure level and the need for aggressive treatment to achieve blood pressure goals 5, 6.
• The potential benefits and risks of different treatment options, including the use of ACE inhibitors, calcium channel blockers, and combination therapy 3, 5, 4, 6, 7.