What is the initial treatment for new onset hypertension?

Initial Treatment for New Onset Hypertension

The initial treatment for new onset hypertension should begin with lifestyle modifications, followed by pharmacologic therapy with a thiazide/thiazide-like diuretic, ACE inhibitor/ARB, or calcium channel blocker if blood pressure goals are not achieved or if the patient has high cardiovascular risk. 1, 2

Lifestyle Modifications

Lifestyle modifications are the foundation of hypertension treatment and should be prescribed for all patients with elevated blood pressure or stage 1 hypertension not qualifying for immediate drug therapy:

• Sodium restriction to <1500 mg/day or at minimum an absolute reduction of 1000 mg/day 1, 2
• Increased potassium intake (3500-5000 mg/day) through fruits and vegetables 1, 2
• Weight loss for overweight/obese individuals (target ideal body weight or at least 1 kg weight loss) 1
• Regular physical activity (aerobic or dynamic resistance 90-150 min/week or isometric resistance 3 sessions/week) 1, 2
• Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women) 1, 2
• DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced saturated and total fat 1

When to Initiate Pharmacologic Therapy

Pharmacologic therapy should be initiated in the following scenarios:

• Immediately in high-risk patients with CVD, chronic kidney disease, diabetes, or evidence of organ damage 1
• After 3-6 months of lifestyle intervention in low-moderate risk patients with persistent BP elevation 1
• For patients with stage 1 hypertension (130-139/80-89 mmHg) and 10-year ASCVD risk ≥10% 1, 2

First-Line Pharmacologic Therapy

The recommended first-line agents include:

• Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone) 1, 2
• ACE inhibitors (e.g., lisinopril starting at 10 mg daily) 2, 3
• ARBs (e.g., losartan starting at 50 mg daily) 2, 4
• Dihydropyridine calcium channel blockers 1, 2

Special Population Considerations

• For Black patients: Consider starting with an ARB + calcium channel blocker or calcium channel blocker + thiazide-like diuretic 1
• For non-Black patients: Consider starting with an ACE inhibitor or ARB 1
• For patients with specific comorbidities, medication selection should be tailored:
  • Chronic kidney disease: ACE inhibitor or ARB 1, 2
  • Diabetes with albuminuria: ACE inhibitor or ARB 1, 2
  • Heart failure: Beta-blockers along with other agents 2, 5
  • Coronary artery disease: ACE inhibitors or ARBs 2

Monitoring and Follow-up

• Patients initiating drug therapy should be followed approximately monthly for drug titration until BP is controlled 1
• Monitor serum creatinine and potassium levels when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2
• Check laboratory values 7-14 days after initiation or dose changes 2
• Target blood pressure goal is typically <130/80 mmHg for most adults 1, 2

Common Pitfalls to Avoid

• Failing to assess for secondary causes of hypertension in patients with resistant hypertension 1
• Inadequate dosing or monotherapy when combination therapy is needed 1, 6
• Not considering single-pill combinations to improve medication adherence 2
• Overlooking the importance of lifestyle modifications even after initiating pharmacologic therapy 6, 7
• Neglecting to monitor for medication side effects, particularly electrolyte abnormalities with diuretics 2

Treatment Algorithm

1. Step 1: Implement comprehensive lifestyle modifications for all patients 1, 2
2. Step 2: For patients requiring medication:
   • Non-Black patients: Start with low-dose ACE inhibitor/ARB 1
   • Black patients: Start with low-dose ARB + calcium channel blocker or calcium channel blocker + thiazide-like diuretic 1
3. Step 3: If BP goal not achieved after 1 month, increase to full dose 1
4. Step 4: If BP still not at goal, add thiazide/thiazide-like diuretic 1
5. Step 5: If BP remains uncontrolled, add spironolactone or other agents (amiloride, doxazosin, eplerenone, clonidine, or beta-blocker) 1

By following this evidence-based approach, the majority of patients with new onset hypertension can achieve adequate blood pressure control, reducing their risk of cardiovascular events and mortality.