Initial Approach for Antihypertensive Treatment
The recommended initial approach for antihypertensive treatment is to begin with a thiazide or thiazide-like diuretic, angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), or long-acting dihydropyridine calcium channel blocker, with combination therapy preferred for patients with blood pressure ≥160/100 mmHg. 1
Diagnosis and Treatment Thresholds
- Hypertension is diagnosed at blood pressure ≥140/90 mmHg, with pharmacological treatment recommended at this threshold for most adults 1
- For patients with existing cardiovascular disease and systolic blood pressure of 130-139 mmHg, pharmacological treatment is strongly recommended 1
- For patients without cardiovascular disease but with high cardiovascular risk, diabetes, or chronic kidney disease, and systolic blood pressure of 130-139 mmHg, pharmacological treatment is conditionally recommended 1
Initial Medication Selection
First-line Medication Options
- Four major drug classes are recommended as first-line options:
Monotherapy vs. Combination Therapy
- For patients with mild blood pressure elevation (140/90 mmHg to 159/99 mmHg), treatment may begin with monotherapy, though combination therapy is still preferred 2
- For patients with blood pressure ≥160/100 mmHg, initial treatment with two antihypertensive medications is strongly recommended 2
- Single-pill combinations improve medication adherence and should be preferred over separate pills when using combination therapy 2
Effective Drug Combinations
- The following two-drug combinations are effective and well-tolerated:
Special Population Considerations
- For Black patients, initial treatment should include a diuretic or calcium channel blocker, either alone or in combination with a RAS blocker 2
- For patients with diabetes and albuminuria, an ACE inhibitor or ARB is recommended as first-line therapy 2
- For patients with heart failure with reduced ejection fraction, treatment should include an ACE inhibitor (or ARB), beta-blocker, and diuretic if required 2
- For patients with chronic kidney disease, RAS blockers are recommended in the presence of albuminuria 2
Dosing Considerations
- For ACE inhibitors like lisinopril, the recommended initial dose is 10 mg once daily, with usual dosage range of 20-40 mg per day 3
- For calcium channel blockers like amlodipine, the usual initial dose is 5 mg once daily, with maximum dose of 10 mg once daily 4
- For hydrochlorothiazide, the adult initial dose is one capsule given once daily, with total daily doses greater than 50 mg not recommended 5
Lifestyle Modifications
Alongside pharmacological treatment, the following lifestyle modifications are recommended:
- Sodium restriction to <1500 mg/day or reduction of at least 1000 mg/day 1, 2
- Increased potassium intake (3500-5000 mg/day) 1, 2
- Weight loss for overweight/obese patients 1, 2
- Physical activity (aerobic or dynamic resistance 90-150 min/week) 1, 2
- Moderation of alcohol intake (≤2 drinks per day in men, ≤1 per day in women) 1, 2
- DASH-like diet rich in fruits, vegetables, whole grains, and low-fat dairy products 1, 2
Follow-up and Monitoring
- Monthly follow-up visits are recommended until blood pressure target is achieved 2
- For patients treated with ACE inhibitors, ARBs, or diuretics, serum creatinine/eGFR and potassium levels should be monitored at least annually 2
- Home BP monitoring or ambulatory BP monitoring is recommended to confirm diagnosis and monitor treatment effectiveness 2
Target Blood Pressure Goals
- For most patients with hypertension without comorbidities, the target blood pressure goal is <140/90 mmHg 1
- For patients with known cardiovascular disease, a target systolic blood pressure goal of <130 mmHg is strongly recommended 1
- For high-risk patients (those with high cardiovascular risk, diabetes mellitus, chronic kidney disease), a target systolic blood pressure goal of <130 mmHg is conditionally recommended 1
Evidence Strength and Historical Context
The ALLHAT trial, one of the largest hypertension trials, demonstrated that thiazide-type diuretics were superior in preventing major forms of cardiovascular disease compared to calcium channel blockers and ACE inhibitors, and were less expensive 6. However, more recent guidelines have expanded first-line options to include ACE inhibitors, ARBs, and calcium channel blockers alongside thiazide diuretics 1, 2.