What is the best initial treatment for hypertension in adult patients?

Best Initial Treatment for Hypertension in Adult Patients

For adults with hypertension requiring pharmacological treatment, the best initial treatment is any of the following four classes of medications: thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or long-acting dihydropyridine calcium channel blockers (CCBs). 1

Treatment Decision Algorithm

Step 1: Determine Need for Pharmacological Therapy

• BP ≥140/90 mmHg: Initiate immediate pharmacological treatment along with lifestyle modifications 1
• BP 130-139/80-89 mmHg with existing cardiovascular disease: Initiate pharmacological treatment 1
• BP 130-139/80-89 mmHg with high cardiovascular risk, diabetes, or chronic kidney disease: Consider pharmacological treatment 1
• BP 130-139/80-89 mmHg without above conditions: Start with lifestyle modifications for up to 3 months before considering medications 1, 2

Step 2: Select Initial Medication

• First-line options (any of the following classes):
  • Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide) 1, 3
  • ACEIs (e.g., lisinopril) 1, 4
  • ARBs (e.g., losartan) 1, 5
  • Long-acting dihydropyridine CCBs (e.g., amlodipina) 1, 3

Step 3: Consider Patient-Specific Factors

• Black patients: Prefer thiazide diuretics or CCBs 6, 5
• Diabetes with proteinuria or CKD with proteinuria: Prefer ACEIs or ARBs 1, 6
• Heart failure with reduced ejection fraction: Prefer ACEIs or ARBs 1, 7

Step 4: Consider Combination Therapy

• For stage 2 hypertension (≥160/100 mmHg): Start with combination of two different drug classes 1
• Preferred combinations:
  • ACEI or ARB + thiazide diuretic 2, 6
  • ACEI or ARB + CCB 2, 6
  • CCB + thiazide diuretic 6, 3

Important Considerations

Dosing

• Start with standard doses (e.g., lisinopril 10 mg daily) and titrate based on response 4, 3
• For patients already on diuretics, start with lower doses of ACEIs (e.g., lisinopril 5 mg daily) 4

Monitoring and Follow-up

• Stage 1 hypertension with treatment: Reevaluate in 1 month 1
• Stage 2 hypertension: Reevaluate in 1 month 1
• Very high BP (≥180/110 mmHg): Prompt evaluation and treatment within 1 week 1
• Monitor for side effects: Particularly renal function and potassium levels when using ACEIs or ARBs 1, 2

Target Blood Pressure Goals

• General population: <140/90 mmHg 1
• Patients with CVD: <130 mmHg systolic 1
• High-risk patients (diabetes, CKD): <130 mmHg systolic 1

Lifestyle Modifications

Always incorporate these alongside pharmacological therapy:

• Dietary sodium restriction (1200-2300 mg/day) 2, 8
• Regular physical activity (150 minutes moderate or 90 minutes vigorous exercise weekly) 2, 3
• Weight reduction to achieve healthy BMI 2, 8
• Moderation of alcohol consumption 2, 8
• DASH diet (rich in fruits, vegetables, low-fat dairy, reduced saturated fats) 2, 3

Common Pitfalls to Avoid

• Never use ACEIs and ARBs simultaneously - this combination increases risk of adverse effects without additional benefit 1, 6
• Don't delay treatment for laboratory testing in patients with clearly elevated BP 1
• Don't undertreat - more than 70% of patients will eventually require at least two medications 6, 3
• Don't ignore home BP measurements - they help identify white coat hypertension and monitor treatment effectiveness 1, 3
• Don't neglect lifestyle modifications - they enhance the efficacy of pharmacological therapy 3, 8