What is the initial treatment for hypertension?

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 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 with blood pressure >120/80 mmHg:

• Weight management through caloric restriction for overweight/obese individuals 2, 3
• DASH (Dietary Approaches to Stop Hypertension) eating pattern 2, 3
• Sodium restriction (<2,300 mg/day) 2, 3
• Increased potassium intake through fruits and vegetables (8-10 servings/day) 2, 3
• Increased consumption of low-fat dairy products (2-3 servings/day) 2, 3
• Regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) 2, 3, 4
• Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women) 2, 3
• Smoking cessation 2, 3

Pharmacologic Therapy

When to initiate medication:

• For patients with elevated blood pressure (systolic BP or diastolic BP consistently ≥90th percentile for age, sex, and height or ≥120/80 mmHg in adolescents ≥13 years), initiate lifestyle modifications first and consider pharmacologic treatment if target BP is not reached within 3-6 months 5
• For patients with stage 1 hypertension and 10-year ASCVD risk ≥10%, initiate pharmacologic therapy alongside lifestyle modifications 1
• For patients with BP ≥150/90 mmHg, start drug therapy immediately along with lifestyle modifications 3

First-line medication options:

• ACE inhibitors (e.g., lisinopril starting at 10 mg once daily) 6
• Angiotensin receptor blockers (ARBs) 2, 1, 3
• Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide starting at one capsule daily) 7
• Dihydropyridine calcium channel blockers 2, 1, 3

Special Population Considerations

• For Black patients: Consider starting with an ARB + calcium channel blocker or calcium channel blocker + thiazide-like diuretic 1, 3
• For patients with chronic kidney disease or albuminuria (UACR ≥30 mg/g): Use an ACE inhibitor or ARB as first-line therapy 1, 3
• For patients with established coronary artery disease: Consider ACE inhibitor or ARB as first-line therapy 2, 3
• For pregnant women or those planning pregnancy: Avoid ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors 2

Monitoring and Follow-Up

• Monitor blood pressure control with a target of achieving BP goal within 3 months 3
• Check serum creatinine and potassium levels 7-14 days after initiation or dose changes of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2, 3
• Monitor for hypokalemia when using diuretics 2
• Consider home BP monitoring to guide medication adjustments 3
• Schedule monthly visits until BP target is achieved 3

Target Blood Pressure Goals

• For most adults: <130/80 mmHg 1
• For European guidelines: 120-129 mmHg systolic BP, provided treatment is well tolerated 2

Common Pitfalls and Caveats

• Underestimating lifestyle modifications: The DASH diet may be the most effective non-pharmacological treatment for reducing blood pressure 8
• Delayed pharmacologic therapy: Don't wait too long to initiate medications in high-risk patients with CVD, chronic kidney disease, diabetes, or evidence of organ damage 1
• Inadequate dosing: Titrate medications appropriately to achieve BP goals; many patients will require more than one agent 4
• Poor medication adherence: Consider single-pill combinations to improve adherence 2
• Overlooking secondary causes: Assess for potential secondary causes of hypertension before initiating treatment 3