What are the first-line medications for managing hypertension?

First-Line Medications for Managing Hypertension

The first-line medications for managing hypertension include thiazide or thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs). 1

Recommended First-Line Agents

• Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone) are supported by the highest level of evidence for reducing mortality and cardiovascular events 1, 2
• ACE inhibitors (e.g., lisinopril) have demonstrated effectiveness in reducing all-cause mortality in hypertensive patients 3, 4
• ARBs provide similar benefits to ACE inhibitors and are often better tolerated 1
• CCBs (e.g., amlodipine) are effective for blood pressure control and cardiovascular risk reduction 5, 6

Patient-Specific Considerations

• For Black patients: CCBs or thiazide diuretics are more effective as initial therapy than ACE inhibitors 1, 4
• For patients aged 55 or older: CCBs or diuretics are generally more effective as first-line agents 7
• For younger white patients (under 55): ACE inhibitors or ARBs tend to be more effective as initial therapy 7
• For patients with albuminuria: ACE inhibitors or ARBs are recommended as first-line therapy 1

The AB/CD Algorithm Approach

The British Hypertension Society recommends using the AB/CD algorithm to guide treatment decisions:

• A: ACE inhibitors or ARBs
• B: Beta-blockers (less commonly used as first-line)
• C: Calcium channel blockers
• D: Diuretics 7

This approach categorizes patients based on age and ethnicity to determine the most effective initial therapy:

• Younger white patients (<55 years): Start with A or B
• Older white patients (≥55 years) or Black patients of any age: Start with C or D 7

Combination Therapy Considerations

• For most patients with hypertension, a combination of two first-line agents at low doses is recommended as initial therapy for more effective blood pressure control 1
• For patients with BP between 130/80 mmHg and 160/100 mmHg, starting with a single drug may be appropriate 1
• For patients with BP ≥160/100 mmHg, initial therapy with two antihypertensive medications is recommended 1
• Logical combinations include: (ACE inhibitor or ARB) + (CCB or diuretic) 7

Evidence on Comparative Effectiveness

• Thiazide diuretics have shown superior outcomes in preventing heart failure compared to CCBs and ACE inhibitors 1
• CCBs are as effective as diuretics for reducing all cardiovascular events except heart failure 1
• Chlorthalidone has demonstrated superiority to lisinopril in preventing stroke and to amlodipine in preventing heart failure 2

Common Pitfalls and Caveats

• Beta-blockers are no longer recommended as first-line therapy for uncomplicated hypertension due to less favorable outcomes compared to other agents 7
• The combination of beta-blockers and diuretics should be used with caution in patients at high risk for developing diabetes 7
• CCBs may be less protective than other agents against the development of heart failure 7
• Many patients will require multiple drugs to achieve blood pressure goals 3, 5
• Despite the availability of effective medications, only about 44% of US adults with hypertension have their blood pressure adequately controlled 4