What is the first-line treatment for a patient with hypertension and a blood pressure reading of 160/90 mmHg?

First-Line Treatment for Hypertension with Blood Pressure 160/90 mmHg

For a patient with hypertension and a blood pressure reading of 160/90 mmHg, immediate initiation of both lifestyle interventions and antihypertensive drug therapy is recommended, with specific medication choices based on patient demographics. 1

Initial Assessment and Classification

• This blood pressure reading (160/90 mmHg) classifies as Grade 2 Hypertension, requiring prompt treatment 1
• Confirmation of the elevated reading should be done using a validated device with appropriate cuff size 2
• Target: Reduce BP by at least 20/10 mmHg initially, with ultimate goal of <130/80 mmHg 1

Immediate Treatment Approach

Pharmacological Therapy

For Non-Black Patients:

• Start with low-dose ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB) 1
• Lisinopril (ACEI) is an appropriate first-line agent that has been shown to lower blood pressure and reduce cardiovascular risk 3
• Consider increasing to full dose if target BP is not achieved 1
• Add a thiazide/thiazide-like diuretic if BP remains uncontrolled 1

For Black Patients:

• Start with low-dose ARB plus dihydropyridine calcium channel blocker (DHP-CCB) or DHP-CCB plus thiazide/thiazide-like diuretic 1
• Amlodipine (DHP-CCB) is an effective option as it produces vasodilation resulting in reduction of blood pressure 4
• Increase to full dose if needed 1

Lifestyle Interventions (to be started concurrently)

• Weight loss if overweight or obese 1
• DASH-style eating pattern with reduced sodium (<2,300 mg/day) and increased potassium intake 1, 5
• Regular physical activity (30-60 minutes, 4-7 days per week) 5, 6
• Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women) 1
• Smoking cessation if applicable 5

Follow-up and Monitoring

• Schedule follow-up within 2-4 weeks to assess response to therapy 2
• Aim to achieve target BP within 3 months 1
• For patients on ACEI, ARB, or diuretic, monitor serum creatinine/eGFR and potassium levels at least annually 1
• Consider home BP monitoring to track progress and improve adherence 2

Important Considerations and Pitfalls

• Single-pill combinations may improve adherence and should be considered 1, 7
• Avoid combining ACE inhibitors with ARBs as this combination increases adverse effects without additional benefit 1
• Most patients will require multiple medications to achieve target BP 8, 7
• For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), an ACEI or ARB should be included in the regimen 1
• If BP remains uncontrolled on a three-drug regimen, consider adding spironolactone 1
• Be vigilant for potential side effects such as hyperkalemia with ACEI/ARB therapy, especially in patients with reduced kidney function 1

Special Populations

• For patients with diabetes, an ACEI or ARB is recommended as first-line therapy 1
• For elderly patients (>80 years) or frail individuals, consider monotherapy and more gradual BP reduction 1
• For patients with established coronary artery disease, ACEI or ARB is preferred first-line therapy 1