What is the first line of treatment for hypertension?

First-Line Treatment for Hypertension

The first-line treatment for hypertension includes lifestyle modifications for all patients, followed by pharmacological therapy with ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers when medication is indicated. 1, 2

Lifestyle Modifications

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

• Adopt a healthy dietary pattern such as Mediterranean or DASH diet with reduced sodium (<2,300 mg/day) and increased potassium intake 1, 2
• Aim for a stable and healthy BMI (20-25 kg/m²) and appropriate waist circumference (<94 cm in men, <80 cm in women) 1, 2
• Engage in regular physical activity (at least 150 minutes of moderate-intensity aerobic activity weekly) complemented with resistance training 2-3 times/week 1, 2
• Limit alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) or preferably avoid alcohol consumption 1, 2
• Smoking cessation for all patients 1, 2

Pharmacological Therapy

When medications are indicated, four primary classes are recommended as first-line options:

• ACE inhibitors (e.g., lisinopril) 1, 2
• ARBs (e.g., candesartan) 1, 2
• Thiazide-like diuretics (preferably long-acting agents like chlorthalidone or indapamide) 1, 2
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2

Initial Treatment Strategy Based on BP Severity

The initial pharmacological approach depends on the severity of hypertension:

• For BP between 130/80 mmHg and 150/90 mmHg: Consider starting with a single agent from one of the four first-line classes 2, 3
• For BP ≥150/90 mmHg or ≥160/100 mmHg: Start with two-drug combination therapy 1, 2
• For most patients with confirmed hypertension (BP ≥140/90 mmHg): Combination therapy is recommended as initial treatment 1

Preferred Combinations and Formulations

• Preferred combinations include a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or a thiazide-like diuretic 1, 2
• Fixed-dose single-pill combinations are recommended to improve adherence 1, 2
• If BP is not controlled with a two-drug combination, a three-drug combination is recommended (RAS blocker + dihydropyridine CCB + thiazide-like diuretic) 1

Special Considerations

• For patients with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB is recommended as first-line therapy 1, 2
• For patients with coronary artery disease: ACE inhibitor or ARB is recommended as first-line therapy 1, 2
• For Black patients: Calcium channel blockers or thiazide diuretics may be more effective than ACE inhibitors or ARBs when used as monotherapy 2
• Beta-blockers are recommended when there are specific indications (e.g., angina, post-myocardial infarction, heart failure with reduced ejection fraction) 1

Important Caveats and Monitoring

• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended due to increased risk of adverse effects 1, 2
• Monitor serum creatinine, estimated glomerular filtration rate, and potassium levels at least annually for patients on ACE inhibitors, ARBs, or diuretics 1, 2
• BP target should generally be 120-129 mmHg systolic for most adults to reduce cardiovascular risk 1, 3
• If BP-lowering treatment is poorly tolerated, target a systolic BP that is "as low as reasonably achievable" 1
• Maintain BP-lowering drug treatment lifelong, even beyond age 85 years, if well tolerated 1

Treatment of Resistant Hypertension

• For patients not meeting BP targets on three classes of antihypertensive medications (including a diuretic), consider adding a mineralocorticoid receptor antagonist 1
• Regular monitoring of serum creatinine and potassium is particularly important when using mineralocorticoid receptor antagonists in combination with RAS blockers 1