What are the first-line treatments for Hypertension (HTN)?

First-Line Treatments for Hypertension (HTN)

The first-line treatments for hypertension include lifestyle modifications and four primary classes of antihypertensive medications: ACE inhibitors, ARBs, thiazide-like diuretics, and dihydropyridine calcium channel blockers. 1

Lifestyle Modifications

Lifestyle modifications should be implemented for all patients with blood pressure >120/80 mmHg:

• Weight loss for overweight or obese individuals through caloric restriction 1, 2
• DASH (Dietary Approaches to Stop Hypertension) eating pattern with reduced sodium (<2,300 mg/day) and increased potassium intake 1, 2
• Regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) 1, 3
• Moderation of alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) 1, 4
• Smoking cessation 1, 2

These lifestyle interventions can lower blood pressure, enhance medication effectiveness, and promote overall metabolic and vascular health with minimal adverse effects 1, 5.

Pharmacologic Therapy

First-Line Medication Classes

Four medication classes have demonstrated efficacy in reducing cardiovascular events in people with hypertension:

1. ACE inhibitors (e.g., lisinopril) 1, 6
2. Angiotensin Receptor Blockers (ARBs) 1
3. Thiazide-like diuretics (preferably long-acting agents like chlorthalidone or indapamide) 1
4. Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 7

Initial Treatment Strategy Based on BP Severity

• BP between 130/80 mmHg and 150/90 mmHg: May begin with a single drug 1
• BP ≥150/90 mmHg or ≥160/100 mmHg: Initial treatment with two antihypertensive medications is recommended for more effective BP control 1

Special Considerations for Medication Selection

• Patients with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB is recommended as first-line therapy 1
• Patients with established coronary artery disease: ACE inhibitor or ARB is recommended as first-line therapy 1
• Black patients: May have better response to calcium channel blockers or thiazide diuretics than to ACE inhibitors or ARBs when used as monotherapy 1, 7

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
• Follow-up 7-14 days after initiation or dose changes of these medications 1
• ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential who are not using reliable contraception 1

Treatment Algorithm

1. Start with lifestyle modifications for all patients with BP >120/80 mmHg 1, 5
2. For BP 130/80-150/90 mmHg:
   • Begin with a single agent from one of the four first-line classes 1
   • Choose ACE inhibitor or ARB if patient has albuminuria or coronary artery disease 1
3. For BP ≥150/90 mmHg:
   • Start with two medications (consider single-pill combinations to improve adherence) 1
4. If BP goal not achieved:
   • Titrate dose to maximum tolerated 1
   • Add additional agents from complementary classes 1
5. For resistant hypertension (BP not controlled on 3 agents including a diuretic):
   • Consider adding a mineralocorticoid receptor antagonist 1

Important Caveats

• Avoid combining ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 1
• Single-pill combinations may improve medication adherence 1
• BP targets should generally be <130/80 mmHg for most adults, with individualization for elderly patients based on frailty 1
• Regular monitoring of kidney function and electrolytes is essential with many antihypertensive medications 1

Remember that hypertension control reduces the risk of cardiovascular events, primarily strokes and myocardial infarctions, and most patients will require more than one drug to achieve blood pressure goals 6, 7, 5.