What is the initial pharmacological management for hypertension?

Initial Pharmacological Management for Hypertension

For adults with hypertension requiring pharmacologic treatment, first-line therapy should include drugs from one of the following classes: thiazide or thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or long-acting dihydropyridine calcium channel blockers. 1

Blood Pressure Thresholds for Initiating Treatment

• Pharmacological treatment should be initiated for individuals with confirmed hypertension and systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg 1
• Treatment should also be started for individuals with existing cardiovascular disease and SBP of 130-139 mmHg 1
• For individuals without cardiovascular disease but with high cardiovascular risk, diabetes mellitus, or chronic kidney disease, treatment should be considered when SBP is 130-139 mmHg 1

First-Line Medication Selection

Single-Drug Therapy

• For patients with BP between 140/90 mmHg and 159/99 mmHg, treatment may begin with a single drug from one of the recommended first-line classes 1
• Selection of initial medication should consider:
  • Patient comorbidities (e.g., diabetes, chronic kidney disease, coronary artery disease) 1
  • Demographic factors (e.g., race/ethnicity) 1
  • Potential side effect profile 1

Combination Therapy

• For patients with BP ≥160/100 mmHg, initial treatment with two antihypertensive medications is recommended 1
• Combination therapy, preferably as a single-pill combination to improve adherence, may be considered as initial treatment 1
• Effective two-drug combinations include:
  • Thiazide diuretic + ACE inhibitor
  • Thiazide diuretic + ARB
  • Calcium antagonist + ACE inhibitor
  • Calcium antagonist + ARB 1

Special Considerations

Patients with Albuminuria

• For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), initial treatment should include an ACE inhibitor or ARB 1
• For those with significant albuminuria (≥300 mg/g creatinine), an ACE inhibitor or ARB at maximum tolerated dose is strongly recommended 1

Patients with Coronary Artery Disease

• In patients with diabetes and established coronary artery disease, ACE inhibitors or ARBs are recommended as first-line therapy 1

Race/Ethnicity Considerations

• In Black patients, thiazide diuretics or calcium channel blockers may be more effective as initial therapy than ACE inhibitors 1
• ARBs may be better tolerated than ACE inhibitors in Black patients, with less cough and angioedema 1

Monitoring and Follow-up

• Serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually for patients treated with an ACE inhibitor, ARB, or diuretic 1
• Monthly follow-up is suggested after initiation or change in antihypertensive medications until target BP is reached 1
• For patients with controlled BP, follow-up every 3-5 months is recommended 1

Target Blood Pressure Goals

• For patients without comorbidities: <140/90 mmHg 1
• For patients with known cardiovascular disease: <130 mmHg systolic 1
• For high-risk patients (high cardiovascular risk, diabetes mellitus, chronic kidney disease): <130 mmHg systolic 1

Common Pitfalls to Avoid

• Avoid combinations of ACE inhibitors and ARBs due to lack of additional benefit and increased risk of adverse events (hyperkalemia, syncope, acute kidney injury) 1
• Avoid combinations of ACE inhibitors or ARBs with direct renin inhibitors 1
• Do not delay treatment to complete cardiovascular risk assessment; this can be done after initiation of therapy 1
• For patients with impaired renal function, monitor for hyperkalemia and acute kidney injury when using ACE inhibitors, ARBs, or diuretics 1

Remember that lifestyle modifications (weight loss, healthy dietary pattern, physical activity, sodium restriction, and alcohol moderation) should accompany pharmacological therapy for optimal blood pressure control 2.