What is the first line treatment for Hypertension (HTN)?

First-Line Treatment for Hypertension

The first-line treatment for hypertension includes lifestyle modifications and pharmacological therapy with one of four medication classes: thiazide or thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or calcium channel blockers (CCBs). 1, 2, 3

Lifestyle Modifications

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

• Weight loss or maintenance of healthy body weight for overweight or obese individuals 2, 4
• DASH (Dietary Approaches to Stop Hypertension) eating pattern with reduced sodium (<2,300 mg/day) and increased potassium intake 2, 4
• Regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) 2, 4
• Moderation of alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) 2, 4
• Smoking cessation 2, 4

Pharmacological Therapy

First-Line Medication Classes

Four medication classes are recommended as first-line therapy:

• Thiazide or thiazide-like diuretics (preferably long-acting agents like chlorthalidone or indapamide) 1, 2
• ACE inhibitors (e.g., lisinopril) 1, 2, 5
• ARBs 1, 2
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2, 6

Initial Treatment Strategy Based on BP Severity

• For patients with BP between 130/80 mmHg and 150/90 mmHg: Start with a single drug 2
• For patients with BP ≥150/90 mmHg: Initial treatment with two antihypertensive medications 2

Special Population Considerations

Black Patients

• Calcium channel blockers or thiazide diuretics are recommended as first-line monotherapy 1, 2
• When combination therapy is needed, use a CCB plus a thiazide-like diuretic or CCB plus an ARB 1

Patients with Albuminuria or Coronary Artery Disease

• ACE inhibitor or ARB is recommended as first-line therapy 2

Treatment Algorithm

1. Stage 1 Hypertension (BP 130-159/80-99 mmHg):

   • Start with lifestyle modifications for all patients 1, 2
   • For high-risk patients (CVD, CKD, diabetes, organ damage, or aged 50-80 years): Start drug therapy immediately 1
   • For others: Trial of lifestyle modifications for 3-6 months; if BP remains elevated, start drug therapy 1

2. For Non-Black Patients:

   • Start with low-dose ACE inhibitor or ARB 1
   • If needed, increase to full dose 1
   • Add thiazide/thiazide-like diuretic if BP remains uncontrolled 1

3. For Black Patients:

   • Start with low-dose ARB plus CCB or CCB plus thiazide/thiazide-like diuretic 1
   • If needed, increase to full dose 1
   • Add diuretic or ACE inhibitor/ARB if BP remains uncontrolled 1

Important Considerations

• Target BP should generally be <130/80 mmHg for most adults, with individualization for elderly patients based on frailty 1, 2
• Monitor serum creatinine and potassium levels when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2
• Single-pill combinations may improve medication adherence 2
• Avoid combining ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 2
• For patients with resistant hypertension, consider adding spironolactone or other agents (amiloride, doxazosin, eplerenone, clonidine, or beta-blocker) 1

Monitoring

• Follow-up is recommended 7-14 days after initiation or dose changes of medications 2
• Aim to achieve BP target within 3 months 1
• Regular monitoring of kidney function and electrolytes is essential with many antihypertensive medications 2