What is the initial treatment approach for hypertension?

Initial Treatment Approach 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 or if the patient has high cardiovascular risk. 1

Lifestyle Modifications

Lifestyle modifications form the foundation of hypertension treatment and should be implemented for all patients:

• Weight loss for overweight individuals with blood pressure >120/80 mmHg through caloric restriction 2
• DASH (Dietary Approaches to Stop Hypertension) eating pattern for patients with blood pressure >120/80 mmHg 2
• Sodium restriction (<2,300 mg/day) for patients with blood pressure >120/80 mmHg 2
• Increased potassium intake through fruits and vegetables (8-10 servings/day) 2, 3
• Regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) 2, 4
• Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women) 2, 5
• Smoking cessation for all patients with blood pressure >120/80 mmHg 2

Pharmacologic Therapy

If blood pressure goals are not achieved with lifestyle modifications alone within 3-6 months, or immediately in high-risk patients, pharmacologic therapy should be initiated:

• For patients with stage 1 hypertension (systolic blood pressure 130-139 mmHg or diastolic blood pressure 80-89 mmHg), begin with a single antihypertensive agent 2, 4
• For patients with stage 2 hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg), consider initiating treatment with two antihypertensive medications 2

First-line Medication Options:

• Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide) 2, 1, 4
• ACE inhibitors (e.g., lisinopril) 2, 1, 6
• Angiotensin receptor blockers (ARBs) (e.g., losartan) 2, 1, 7
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 2, 1, 4

Medication Selection Considerations:

• For patients with chronic kidney disease or albuminuria, an ACE inhibitor or ARB is recommended as first-line therapy 2, 1
• For Black patients, consider starting with a calcium channel blocker or thiazide-like diuretic 1
• For patients with heart failure, include a beta-blocker in addition to other agents 2
• For pregnant women or those planning pregnancy, avoid ACE inhibitors and ARBs 2

Dosing and Titration

• For ACE inhibitors such as lisinopril, the recommended initial dose is 10 mg once daily, with usual dosage range of 20-40 mg per day 6
• For ARBs such as losartan, the usual starting dose is 50 mg once daily, with maximum dose of 100 mg once daily as needed 7
• If blood pressure is not controlled with monotherapy, add a second agent from a different class 2, 4
• Consider single-pill combinations to improve medication adherence 2

Monitoring and Follow-up

• Monitor serum creatinine and potassium levels when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2, 1
• Check laboratory values 7-14 days after initiation or dose changes of these medications 2
• Monitor for hypokalemia when using diuretics 2
• Titrate medications or add additional agents if blood pressure goals are not achieved 2

Target Blood Pressure Goals

• The target blood pressure goal is typically <130/80 mmHg for most adults 1, 4
• For adults ≥65 years, a systolic blood pressure target of <130 mmHg is recommended if well tolerated 2, 4