What is the initial treatment for hypertension?

Initial Treatment for Hypertension

The initial treatment for hypertension should begin with lifestyle modifications, and if blood pressure targets are not achieved within 3-6 months, pharmacological therapy with ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers should be initiated. 1, 2

Diagnosis and Assessment

• Confirm hypertension diagnosis using validated automated upper arm cuff device with appropriate cuff size, measuring BP in both arms at first visit 2
• Hypertension is defined as office BP ≥130/85 mmHg, confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 2
• Assess for target organ damage, cardiovascular risk factors, and potential secondary causes of hypertension 2

Lifestyle Modifications as First-Line Treatment

• Weight management through caloric restriction for overweight/obese patients with BP >120/80 mmHg 1, 2, 3
• DASH (Dietary Approaches to Stop Hypertension) eating pattern, including:
  • Sodium restriction (<2,300 mg/day) 1, 2
  • Increased potassium intake (8-10 servings of fruits and vegetables daily) 1, 2
  • Low-fat dairy products consumption (2-3 servings daily) 1, 2
• Regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) 1, 2, 3
• Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) 1, 2
• Complete smoking cessation 1, 2

Pharmacological Therapy

• If target blood pressure is not reached within 3-6 months of initiating lifestyle intervention, pharmacologic treatment should be considered 4, 2
• Start drug therapy immediately along with lifestyle modifications for patients with BP ≥150/90 mmHg 2
• First-line drug therapy options include:
  • ACE inhibitors (e.g., lisinopril, starting dose 10 mg daily) 1, 2, 5
  • ARBs (e.g., losartan, starting dose 50 mg daily) 1, 2, 6
  • Thiazide-like diuretics 1, 2, 3
  • Dihydropyridine calcium channel blockers 1, 2, 3
• Consider initial treatment with two antihypertensive medications for more effective BP control in patients with BP ≥150/90 mmHg 1, 2

Special Population Considerations

• For Black patients: Consider starting with ARB + dihydropyridine calcium channel blocker or calcium channel blocker + thiazide-like diuretic 2
• For patients with albuminuria (UACR ≥30 mg/g): Use ACE inhibitor or ARB as first-line therapy 1, 2
• For patients with established coronary artery disease: Use ACE inhibitor or ARB as first-line therapy 1, 2
• For elderly patients (>80 years) or frail individuals: Consider starting with monotherapy at lower doses 2
• For pregnant women or those planning pregnancy: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated 1

Monitoring and Follow-Up

• Monitor BP control with a target of achieving BP goal within 3 months 2
• Check serum creatinine and potassium 7-14 days after initiation or dose changes for patients on ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1, 2
• Consider home BP monitoring to guide medication adjustments 2
• Schedule monthly visits until BP target is achieved 2

Target Blood Pressure Goals

• Target systolic blood pressure of 120-129 mmHg for most adults, provided the treatment is well tolerated 1
• For patients with diabetes mellitus or chronic kidney disease, target BP <130/80 mmHg 4
• For other patients, target BP <140/90 mmHg 4

Common Pitfalls to Avoid

• Failing to confirm hypertension with multiple readings before initiating treatment 2
• Not allowing adequate time (3-6 months) for lifestyle modifications to take effect before starting medications 4, 2
• Overlooking medication adherence issues when BP goals are not achieved 1
• Not monitoring laboratory values after starting ACE inhibitors or ARBs 1, 2
• Using ACE inhibitors or ARBs in pregnant women or women planning pregnancy 1