What is a reasonable first-line treatment option for managing hypertension (high blood pressure)?

First-Line Treatment for Hypertension Management

For most patients with confirmed hypertension, a low-dose combination of two first-line agents (thiazide/thiazide-like diuretic, ACE inhibitor, ARB, or calcium channel blocker) is recommended as initial therapy, preferably as a single pill combination. 1, 2

First-Line Medication Options

• The major four drug classes recommended as first-line therapy for hypertension are:

  • Thiazide or thiazide-like diuretics (especially chlorthalidone)
  • Angiotensin-converting enzyme (ACE) inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Calcium channel blockers (CCBs) 1, 2

• Thiazide diuretics, particularly chlorthalidone, have shown superior outcomes in preventing heart failure compared to CCBs and ACE inhibitors 1, 3

• ACE inhibitors and ARBs have been shown to reduce all-cause mortality in hypertensive patients similar to thiazide diuretics 3

Patient-Specific Considerations

• For Black patients, CCBs or thiazide diuretics are more effective as initial therapy compared to ACE inhibitors 1, 2

• For patients with diabetes and established coronary artery disease, ACE inhibitors or ARBs are recommended as first-line therapy 1, 2

• For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), an ACE inhibitor or ARB is recommended as first-line therapy 1, 2

Treatment Approach Based on BP Severity

• For patients with BP between 140/90 mmHg and 159/99 mmHg (Stage 1 hypertension):

  • Single antihypertensive drug may be reasonable as initial therapy 1
  • Consider cardiovascular risk when making treatment decisions 1

• For patients with BP ≥160/100 mmHg (Stage 2 hypertension):

  • Initial therapy with two antihypertensive medications from different classes is recommended 1
  • Preferably as a single-pill combination to improve adherence 1, 2

Lifestyle Modifications

• All patients should receive counseling on lifestyle modifications alongside pharmacological therapy:
  • Weight loss for overweight/obese patients
  • Reduced sodium intake (<2,300 mg/day)
  • Increased consumption of fruits, vegetables, and low-fat dairy
  • Physical activity
  • Limited alcohol consumption 1, 4

Common Pitfalls and Caveats

• Avoid combination of two RAS blockers (ACE inhibitor + ARB or either with direct renin inhibitor) as this increases risk of hyperkalemia, syncope, and acute kidney injury without additional cardiovascular benefit 1

• Monitor serum creatinine, estimated glomerular filtration rate, and potassium levels at least annually in patients treated with ACE inhibitors, ARBs, or diuretics 1

• Many patients will require multiple drugs to achieve blood pressure goals - be prepared to add additional agents if target BP is not achieved 5, 4

• Single-pill combinations improve adherence compared to multiple separate pills 1, 2

Follow-Up Recommendations

• For patients with Stage 1 hypertension, repeat BP evaluation within 3-6 months 1

• For patients with Stage 2 hypertension, repeat BP evaluation within 1 month 1

• For patients with very high BP (≥180/110 mmHg), prompt evaluation and antihypertensive drug treatment is recommended 1