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 loss 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, 4
• Increased potassium intake through 8-10 servings of fruits and vegetables daily 2, 3
• 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
• Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women) 2, 3
• Smoking cessation 2, 3

Pharmacologic Therapy

For patients who do not achieve blood pressure goals with lifestyle modifications alone or who have high cardiovascular risk, pharmacologic therapy should be initiated:

• For patients with stage 1 hypertension (130/80-149/99 mmHg) and 10-year ASCVD risk ≥10%, initiate pharmacologic therapy along with lifestyle modifications 3

• For patients with BP ≥150/90 mmHg, start drug therapy immediately along with lifestyle modifications 3, 1

• First-line drug therapy options include:

  • ACE inhibitors (e.g., lisinopril) 2, 3, 5
  • Angiotensin receptor blockers (ARBs) 2, 3
  • Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide) 2, 3, 6
  • Dihydropyridine calcium channel blockers 2, 3

• Consider initial treatment with two antihypertensive medications for more effective BP control in patients with BP ≥150/90 mmHg 3

Special Population Considerations

• For Black patients: Consider starting with an ARB + dihydropyridine calcium channel blocker or calcium channel blocker + thiazide-like diuretic 3
• For patients with albuminuria (UACR ≥30 mg/g): Use ACE inhibitor or ARB as first-line therapy 3
• For patients with established coronary artery disease: Use ACE inhibitor or ARB as first-line therapy 2, 3
• For older patients (>80 years) or frail individuals: Consider starting with monotherapy at lower doses 3

Medication Dosing

• Lisinopril (ACE inhibitor): Initial dose 10 mg once daily, with usual dosage range of 20-40 mg per day 5
• Hydrochlorothiazide: Initial dose is one capsule (typically 12.5 or 25 mg) given once daily 6
• If blood pressure is not controlled with ACE inhibitor alone, a low dose of a diuretic may be added (e.g., hydrochlorothiazide 12.5 mg) 5

Monitoring and Follow-Up

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

Target Blood Pressure Goals

• The target blood pressure goal is typically <130/80 mmHg for most adults 1, 7
• For adults ≥65 years, target systolic BP <130 mmHg 7

Common Pitfalls to Avoid

• Failing to try lifestyle modifications before or alongside pharmacologic therapy 4, 7
• Not accounting for patient characteristics (age, race, comorbidities) when selecting initial medication 3
• Inadequate follow-up monitoring of medication effects and laboratory values 2, 3
• Using ACE inhibitors or ARBs in pregnant women or those planning pregnancy 2
• Neglecting to continue lifestyle modifications after initiating drug therapy 8