Initial Pharmacological Therapies for Treating Hypertension
The first-line pharmacological agents for treating hypertension include thiazide and thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and long-acting dihydropyridine calcium channel blockers (CCBs). 1, 2
Blood Pressure Thresholds for Initiating Treatment
- Pharmacological treatment is recommended for individuals with confirmed hypertension and systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg 2
- For patients with high cardiovascular risk, diabetes mellitus, or chronic kidney disease, treatment should be considered when SBP is 130-139 mmHg 1, 2
- For patients with known cardiovascular disease, treatment is recommended when SBP is 130-139 mmHg 1, 2
First-Line Medication Selection
Any of these four drug classes can be used as initial therapy based on their proven efficacy in reducing cardiovascular events in people with hypertension 1:
- Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide)
- ACE inhibitors (e.g., lisinopril)
- ARBs (e.g., losartan)
- Long-acting dihydropyridine calcium channel blockers (e.g., amlodipine)
Initial medication selection should be guided by patient-specific factors 1, 2:
- For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), an ACE inhibitor or ARB is recommended 1, 2
- For patients with diabetes and established coronary artery disease, ACE inhibitors or ARBs are preferred 1
- For Black patients, thiazide diuretics or CCBs may be more effective as initial therapy than ACE inhibitors 1, 2
Single vs. Combination Therapy Approach
- For patients with BP between 130/80 mmHg and 150/90 mmHg, treatment may begin with a single agent 1
- For patients with BP ≥150/90 mmHg or with BP more than 20/10 mmHg above their target, initial therapy with two antihypertensive medications from different classes is recommended 1
- Single-pill combinations may improve medication adherence 1
Dosing and Titration
- For ACE inhibitors like lisinopril, the recommended initial dose is 10 mg once daily, with typical dosage range of 20-40 mg per day 3
- For ARBs like losartan, the usual starting dose is 50 mg once daily, which can be increased to a maximum of 100 mg once daily as needed 4
- If blood pressure is not controlled with monotherapy, a low dose of a diuretic may be added (e.g., hydrochlorothiazide 12.5 mg) 3
Target Blood Pressure Goals
- For patients without comorbidities, the target blood pressure goal is <140/90 mmHg 1, 2
- For patients with known cardiovascular disease, the target systolic blood pressure goal is <130 mmHg 1, 2
- For high-risk patients (high cardiovascular risk, diabetes mellitus, or chronic kidney disease), the target systolic blood pressure goal is <130 mmHg 1
Monitoring and Follow-up
- Monthly follow-up is recommended after initiation or change in antihypertensive medications until target BP is reached 1
- For patients with controlled BP, follow-up every 3-5 months is suggested 1
- Monitor serum creatinine and potassium levels when using ACE inhibitors, ARBs, or diuretics 1
Common Pitfalls to Avoid
- Avoid combinations of ACE inhibitors and ARBs due to increased risk of adverse events without additional benefit 2
- Do not use immediate-release nifedipine due to risk of rapid blood pressure reduction 5
- Avoid delaying treatment to complete cardiovascular risk assessment; this can be done after initiation of therapy 2
- Beta-blockers are not recommended as first-line therapy unless there are specific indications such as prior myocardial infarction, active angina, or heart failure 1
Special Considerations
- In patients with impaired renal function, dose adjustments may be necessary for ACE inhibitors and ARBs 3, 4
- ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists should be avoided in sexually active individuals of childbearing potential who are not using reliable contraception 1
- For resistant hypertension (BP ≥140/90 mmHg despite three antihypertensive medications including a diuretic), consider adding a mineralocorticoid receptor antagonist 1