What is the first-line treatment for Hypertension (High Blood Pressure)?

From the Guidelines

The first-line treatment for hypertension should be ACE inhibitors, ARBs, dihydropyridine CCBs, or diuretics, as these have demonstrated the most effective reduction of blood pressure and cardiovascular disease events. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, these classes of medications are recommended as first-line treatments due to their efficacy in lowering blood pressure and reducing cardiovascular events.

Key Recommendations

• ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics are recommended as first-line treatments for hypertension 1.
• Combination therapy with a RAS blocker (either an ACE inhibitor or an ARB) and a dihydropyridine CCB or diuretic is preferred for most patients with confirmed hypertension 1.
• Beta-blockers may be used in combination with other medications when there are compelling indications, such as angina, post-myocardial infarction, or heart failure with reduced ejection fraction 1.
• Lifestyle modifications, including reducing sodium intake, maintaining a healthy weight, regular physical activity, limiting alcohol consumption, and following a DASH diet, are essential companions to medication 1.

Medication Options

• ACE inhibitors, such as lisinopril (10-40 mg daily), may be preferred for younger patients or those with diabetes or kidney disease 1.
• ARBs, such as losartan (25-100 mg daily), may be used as an alternative to ACE inhibitors 1.
• Dihydropyridine CCBs, such as amlodipine (5-10 mg daily), may be used, particularly in elderly patients or those of African descent 1.
• Diuretics, such as hydrochlorothiazide (12.5-25 mg daily) or chlorthalidone (12.5-25 mg daily), may be used due to their efficacy, safety profile, and cost-effectiveness 1.

Treatment Approach

• Treatment should start with a low dose and be titrated upward if blood pressure remains above target (typically <130/80 mmHg) 1.
• If a single agent does not achieve target blood pressure after dose optimization, combination therapy with agents from different classes is recommended 1.

From the FDA Drug Label

Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. Many patients will require more than 1 drug to achieve blood pressure goals. Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits

The first-line treatment for Hypertension (High Blood Pressure) is not explicitly stated in the provided drug labels. However, lisinopril is indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure 2.

• Lisinopril can be used alone or with other antihypertensive agents.
• The choice of therapy should be guided by published guidelines and consideration of the patient's individual characteristics, such as the presence of other health conditions like diabetes or hyperlipidemia.
• It is also important to note that many patients may require more than one drug to achieve their blood pressure goals.

From the Research

First-Line Treatment for Hypertension

The first-line treatment for hypertension (high blood pressure) is lifestyle modification, which includes:

• Weight loss
• Healthy dietary pattern with low sodium and high potassium intake
• Physical activity
• Moderation or elimination of alcohol consumption 3, 4 This approach is recommended for patients with high-normal blood pressure or grade 1 hypertension without high risk factors, and should be tried for 3-6 months before starting medication 3.

Lifestyle Modifications

Lifestyle modifications are crucial in the treatment of hypertension and should be recommended to most hypertensive patients. The most effective lifestyle interventions for reducing blood pressure include:

• Diet adaptation with low sodium and alcohol restriction
• Physical exercise
• Weight reduction 3, 4 The Dietary Approaches to Stop Hypertension (DASH) diet may be considered the most effective treatment for reducing blood pressure 3.

Pharmacologic Therapy

When pharmacologic therapy is required, first-line therapies include:

• Thiazide or thiazide-like diuretics
• Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers
• Calcium channel blockers 4, 5, 6, 7 These medications should be titrated according to office and home blood pressure levels to achieve a target blood pressure of less than 130/80 mm Hg for adults under 65 years and less than 130 mm Hg for adults 65 years and older 4.