What is the initial treatment algorithm for hypertension?

Initial Treatment Algorithm for Hypertension

The initial treatment algorithm for hypertension begins with lifestyle modifications for all patients with blood pressure >120/80 mmHg, followed by pharmacologic therapy based on blood pressure severity, with single-agent therapy for BP 130/80-150/90 mmHg and dual-agent therapy for BP ≥150/90 mmHg, prioritizing ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers as first-line agents. 1

Step 1: Lifestyle Modifications

For all patients with blood pressure >120/80 mmHg, implement the following lifestyle interventions:

• Weight loss for overweight individuals through caloric restriction 1
• DASH (Dietary Approaches to Stop Hypertension) eating pattern 1
• Sodium restriction (<2,300 mg/day) 1
• Increased potassium intake through fruits and vegetables (8-10 servings/day) 1
• Increased consumption of low-fat dairy products (2-3 servings/day) 1
• Regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) 1
• Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women) 1
• Smoking cessation 1

These lifestyle modifications can lower blood pressure, enhance the effectiveness of antihypertensive medications, and promote overall cardiovascular health 1, 2.

Step 2: Pharmacologic Therapy Based on BP Severity

For BP between 130/80 mmHg and 150/90 mmHg:

• Begin with a single antihypertensive agent 1

For BP ≥150/90 mmHg:

• Initiate treatment with two antihypertensive medications to more effectively achieve blood pressure goals 1
• Consider single-pill combinations to improve medication adherence 1

Step 3: First-Line Medication Selection

Choose from these first-line drug classes that have demonstrated cardiovascular event reduction in people with diabetes and hypertension 1:

• ACE inhibitors (e.g., lisinopril) 1, 3
• ARBs (e.g., losartan) 1, 4
• Thiazide-like diuretics (preferably long-acting agents like chlorthalidone or indapamide) 1
• Dihydropyridine calcium channel blockers 1

Special Considerations for Medication Selection

• For patients with coronary artery disease: ACE inhibitors or ARBs are recommended as first-line therapy 1
• For patients with albuminuria (UACR ≥30 mg/g): Initial treatment should include an ACE inhibitor or ARB to reduce risk of progressive kidney disease 1
• For patients with heart failure: Beta-blockers are indicated in addition to other agents 1
• For pregnant women or those planning pregnancy: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated 1

Step 4: Monitoring and Follow-Up

• Monitor serum creatinine and potassium levels when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Monitor for hypokalemia when using diuretics 1
• Check laboratory values 7-14 days after initiation or dose changes of these medications 1
• Titrate medications or add additional agents if blood pressure goals are not achieved 1

Step 5: Management of Resistant Hypertension

For patients not meeting blood pressure targets on three classes of antihypertensive medications (including a diuretic):

• Consider adding a mineralocorticoid receptor antagonist 1
• Consider referral to a specialist with expertise in blood pressure management 1

Common Pitfalls to Avoid

• Avoid combining ACE inhibitors with ARBs - this combination increases risk of hyperkalemia and acute kidney injury without additional cardiovascular benefit 1
• Avoid delaying initiation of dual therapy in patients with significantly elevated blood pressure (≥150/90 mmHg) 1
• Avoid therapeutic inertia - titrate medications in a timely fashion to overcome delays in achieving blood pressure targets 1
• Don't overlook medication adherence issues - single-pill combinations may improve adherence 1
• Don't neglect lifestyle modifications even after starting pharmacologic therapy 1, 2

Target Blood Pressure Goals

According to the 2024 European Society of Cardiology guidelines, the recommended target for treated systolic blood pressure in most adults is 120-129 mmHg, provided the treatment is well tolerated 1.