Best Initial Treatment Approach for Managing Hypertension
The best initial treatment approach for hypertension is combination therapy with two antihypertensive medications, preferably as a single-pill combination, using a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker (CCB) or a thiazide/thiazide-like diuretic. 1
Initial Assessment and Treatment Decision
- For patients with confirmed hypertension (BP ≥140/90 mmHg), treatment should include both lifestyle modifications and pharmacological therapy initiated concurrently 1, 2
- Initial medication choice should be based on blood pressure level and cardiovascular risk assessment 1, 3
- For most patients with BP ≥140/90 mmHg, a two-drug combination is recommended as initial therapy 1, 2
- Single-pill combinations improve medication adherence and should be preferred over separate pills 1, 2
First-Line Medication Combinations
- Preferred two-drug combinations include:
- These combinations are effective and well-tolerated for most patients 2, 4
- Combining two RAS blockers (ACE inhibitor and ARB) is not recommended due to increased adverse effects without additional benefit 1
Special Population Considerations
- In Black patients, initial treatment should include a diuretic or calcium channel blocker, either alone or in combination with a RAS blocker 2, 4
- For patients with diabetes and albuminuria, an ACE inhibitor or ARB should be included in the initial regimen 1, 2
- For older patients (≥85 years), those with symptomatic orthostatic hypotension, or moderate-to-severe frailty, a more cautious approach with monotherapy may be appropriate 1
- For patients with heart failure with reduced ejection fraction, treatment should include an ACE inhibitor (or ARB), beta-blocker, and diuretic if required 2
Lifestyle Modifications
- All patients should receive concurrent lifestyle modification advice, including:
- Sodium restriction (<2,300 mg/day) 2, 3
- DASH eating pattern (rich in fruits, vegetables, whole grains, and low-fat dairy products) 2, 3
- Weight loss for overweight/obese patients 2, 3
- Regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) 2, 3
- Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women) 2, 3
Follow-up and Monitoring
- Patients should be seen frequently (every 1-3 months) until BP is controlled 1, 2
- Blood pressure should ideally be controlled within 3 months of starting treatment 1
- For patients treated with ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium levels at least annually 1, 2
- Home BP monitoring is recommended to confirm diagnosis and monitor treatment effectiveness 2
Treatment Escalation
- If BP is not controlled with a two-drug combination, increase to a three-drug combination (usually a RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic), preferably as a single-pill combination 1
- If BP remains uncontrolled with a three-drug combination, adding spironolactone should be considered 1
- For patients who cannot tolerate spironolactone, consider eplerenone, a beta-blocker, a centrally acting medication, an alpha-blocker, or hydralazine 1
Target Blood Pressure Goals
- For most adults, aim for a target systolic BP of 120-129 mmHg, provided the treatment is well tolerated 3
- For patients with diabetes, aim for BP <130/80 mmHg 1
- For patients with chronic kidney disease, aim for a systolic BP of 120-139 mmHg 2
Common Pitfalls to Avoid
- Delaying initiation of pharmacological therapy in patients with confirmed hypertension 1, 2
- Using monotherapy when combination therapy is indicated for patients with BP significantly above target 1, 2
- Combining two RAS blockers (ACE inhibitor and ARB), which increases adverse effects without additional benefit 1
- Neglecting lifestyle modifications when initiating pharmacological therapy 1, 2
- Inadequate follow-up and monitoring of treatment response 2
- Not considering single-pill combinations to improve medication adherence 1, 2