What is the best initial antihypertensive (high blood pressure) medication for a 45-year-old Caucasian female with a Body Mass Index (BMI) of 21 and hypertension?

Best Initial Antihypertensive Medication for a 45-Year-Old Caucasian Female

For a 45-year-old Caucasian female with a BMI of 21 and hypertension, an ACE inhibitor or ARB is the most appropriate first-line medication. 1

First-Line Medication Selection

• For non-Black patients under 60 years of age, an ACE inhibitor or ARB is recommended as initial therapy 1
• The 2020 International Society of Hypertension guidelines specifically recommend starting with a low-dose ACE inhibitor or ARB in non-Black patients 1
• For Caucasian women under 55 years, ACE inhibitors or ARBs have demonstrated better efficacy compared to other classes 1
• The National Institute for Clinical Excellence (NICE) guidelines specifically recommend ACE inhibitors or ARBs for patients under 55 years of age 1

Specific Medication Recommendations

• Lisinopril (ACE inhibitor) has demonstrated superior reductions of systolic and diastolic blood pressure compared to hydrochlorothiazide in Caucasian populations 2
• Starting dose of lisinopril should be 10-20 mg daily, as clinical studies show better blood pressure reduction at these doses compared to 5 mg 2
• Alternatively, an ARB such as losartan can be considered, particularly if the patient develops a cough with an ACE inhibitor 3

Treatment Algorithm

1. Initial therapy: Start with an ACE inhibitor (e.g., lisinopril 10-20 mg daily) or ARB 1, 2
2. Titration: If blood pressure remains uncontrolled after 2-4 weeks, increase to full dose 1
3. Add-on therapy: If target blood pressure is not achieved with monotherapy, add a calcium channel blocker (e.g., amlodipine) 1, 4
4. Further additions: If needed, add a thiazide-like diuretic as a third agent 1

Monitoring and Target Blood Pressure

• Recheck blood pressure within 2-4 weeks after medication initiation 1, 5
• Target blood pressure should be <130/80 mmHg 1, 5
• Monitor for potential side effects, particularly with ACE inhibitors (cough, angioedema) 2

Important Considerations and Caveats

• While thiazide diuretics have been traditionally recommended as first-line therapy, more recent guidelines favor ACE inhibitors or ARBs for younger non-Black patients 1
• A recent Cochrane review found that no antihypertensive drug class demonstrated clinically important advantages over thiazides when used as first-line agents, but this was primarily in older populations (50-75 years) 6
• For this specific patient demographic (45-year-old Caucasian female), ACE inhibitors or ARBs are preferred due to better efficacy and tolerability profiles 1
• Be aware that if the patient later develops conditions such as heart failure, diabetes, or chronic kidney disease, an ACE inhibitor or ARB would remain appropriate first-line therapy 1