What is the initial treatment for Hypertension (HTN)?

Initial Treatment for Hypertension

The initial treatment for 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. 1

Lifestyle Modifications

Lifestyle modifications form the foundation of hypertension treatment and should be recommended for all patients with blood pressure >120/80 mmHg:

• Weight loss for overweight individuals through caloric restriction 2
• DASH (Dietary Approaches to Stop Hypertension) eating pattern, including:
  • Reduced sodium intake (<2,300 mg/day) 3, 2
  • Increased potassium intake through fruits and vegetables (8-10 servings/day) 3, 2
  • Increased consumption of low-fat dairy products (2-3 servings/day) 3, 2
• Regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) 2
• Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women) 3, 2
• Smoking cessation 2

These lifestyle modifications can have significant blood pressure-lowering effects and enhance the efficacy of pharmacologic therapy 4.

Pharmacologic Therapy

When to Initiate Medication

• For patients with blood pressure between 140/90 mmHg and 159/99 mmHg, begin with a single antihypertensive agent 3, 2
• For patients with blood pressure ≥160/100 mmHg, initial pharmacologic treatment with two antihypertensive medications is recommended 3
• Consider immediate pharmacologic therapy in high-risk patients with cardiovascular disease, chronic kidney disease, diabetes, or evidence of organ damage 1

First-Line Medication Options

First-line pharmacologic therapy for hypertension should include one of the following classes:

• Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone) 3, 4
• ACE inhibitors (e.g., lisinopril) 3, 4
• Angiotensin receptor blockers (ARBs) 3, 4
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 3, 4

Special Population Considerations

• For patients with albuminuria (UACR ≥30 mg/g), initial treatment should include an ACE inhibitor or ARB 3, 2
• For patients with established coronary artery disease, ACE inhibitors or ARBs are recommended as first-line therapy 3, 2
• For Black patients, consider starting with a calcium channel blocker or thiazide-like diuretic 1, 4
• For patients with diabetes, ACE inhibitors or ARBs are often preferred 3

Dosing and Titration

• For ACE inhibitors like lisinopril, the recommended initial dose is 10 mg once daily, with a usual dosage range of 20-40 mg per day 5
• For hydrochlorothiazide, the initial dose is one capsule (typically 12.5 or 25 mg) given once daily 6
• If blood pressure is not controlled with a single agent, a second agent can be added 3
• Consider single-pill combinations to improve medication adherence 3, 2

Monitoring and Follow-Up

• Monitor serum creatinine and potassium levels when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 3, 2
• Titrate medications every 2-4 weeks based on blood pressure response 3
• The patient should be seen every 4-6 weeks until blood pressure has normalized 3
• Target blood pressure goal is typically <130/80 mmHg for most adults 1, 4

Common Pitfalls to Avoid

• Avoid combinations of ACE inhibitors and ARBs due to increased risk of hyperkalemia, syncope, and acute kidney injury 3
• Beta-blockers are not recommended as initial treatment for hypertension unless there are specific indications such as prior MI, active angina, or heart failure 3
• ACE inhibitors and ARBs are contraindicated in pregnancy 3, 2
• Be cautious with diuretics in patients with gout or electrolyte abnormalities 3