What medications are recommended for initial treatment of hypertension?

Initial Antihypertensive Medication Selection for Hypertension Treatment

For initial treatment of hypertension, first-line medications should include ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers, with selection based on patient characteristics and comorbidities. 1

Treatment Algorithm Based on Blood Pressure Severity

For BP 140-159/90-99 mmHg:

• Start with a single antihypertensive agent from one of the four major drug classes 1
• For patients with diabetes, chronic kidney disease, or high cardiovascular risk, initiate pharmacological treatment immediately 1
• For low-risk patients, consider a trial of lifestyle modifications for 3-6 months before starting medication 1

For BP ≥160/100 mmHg:

• Immediately initiate treatment with two antihypertensive medications, preferably as a single-pill combination 1
• Recommended combinations: ACE inhibitor or ARB + calcium channel blocker or thiazide-like diuretic 1

Medication Selection Based on Patient Demographics

Non-Black Patients:

• Initial therapy: ACE inhibitor or ARB (e.g., lisinopril 10 mg daily or losartan 50 mg daily) 1, 2, 3
• If BP goal not achieved, add a thiazide-like diuretic or calcium channel blocker 1

Black Patients:

• Initial therapy: Calcium channel blocker or thiazide-like diuretic 1
• If BP goal not achieved, add an ARB (preferred over ACE inhibitor) 1

Specific Comorbidity Considerations

Patients with Albuminuria or Chronic Kidney Disease:

• First choice: ACE inhibitor or ARB 1
• Target dose: Lisinopril 20-40 mg daily or losartan 50-100 mg daily 2, 3

Patients with Heart Failure:

• First choice: ACE inhibitor (e.g., lisinopril starting at 5 mg daily) with a diuretic 2
• Add beta-blockers for patients with reduced ejection fraction 1

Patients with Coronary Artery Disease:

• First choice: ACE inhibitor or ARB 1
• Consider adding beta-blockers for those with prior myocardial infarction 1

Patients with Diabetes:

• First choice: ACE inhibitor or ARB 1
• Add a calcium channel blocker or thiazide-like diuretic if BP goal not achieved 1

Step-wise Treatment Approach

1. Start with one medication at a low dose (monotherapy appropriate for mild hypertension) 1
2. If BP goal not achieved after 4 weeks, either increase the dose or add a second agent 1
3. If BP still not controlled, use triple therapy with ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic 1
4. For resistant hypertension (uncontrolled on 3 drugs including a diuretic), add a mineralocorticoid receptor antagonist like spironolactone 1

Evidence-Based Medication Selection

• Thiazide-like diuretics (chlorthalidone, indapamide) have stronger evidence for cardiovascular event reduction than hydrochlorothiazide 4, 5
• The ALLHAT trial demonstrated that chlorthalidone was superior to lisinopril for stroke prevention and superior to amlodipine for heart failure prevention 5
• Single-pill combinations improve medication adherence 1

Common Pitfalls to Avoid

• Do not combine ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 1
• Avoid using beta-blockers as first-line therapy unless specifically indicated (e.g., coronary artery disease, heart failure) 1
• Do not delay initiation of drug therapy in high-risk patients or those with BP ≥160/100 mmHg 1
• Avoid rapid, excessive BP lowering in chronic hypertension, which may lead to hypoperfusion 6
• Do not use immediate-release nifedipine for hypertensive urgencies due to risk of unpredictable BP drops 6

Treatment Targets

• For most adults: Target BP <130/80 mmHg 1, 7
• For elderly patients (≥65 years): Individualize targets based on frailty, with systolic BP goal of 130-139 mmHg if tolerated 1
• Aim to achieve target BP within 3 months of initiating therapy 1