What is the initial pharmacological approach for managing persistent hypertension?

Initial Pharmacological Management of Persistent Hypertension

For adults with persistent hypertension requiring pharmacological treatment, first-line therapy should include drugs from one of four classes: thiazide/thiazide-like diuretics, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or long-acting dihydropyridine calcium channel blockers (CCBs). 1

Diagnostic Thresholds and Treatment Initiation

• Pharmacological treatment is recommended for individuals with confirmed hypertension and systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg 1
• For patients with existing cardiovascular disease and SBP 130-139 mmHg, pharmacological treatment is strongly recommended 1
• For patients without cardiovascular disease but with high cardiovascular risk, diabetes mellitus, or chronic kidney disease and SBP 130-139 mmHg, pharmacological treatment is conditionally recommended 1

First-Line Medication Selection

Monotherapy Approach

• Any of the following classes can be used as initial monotherapy 1:

  • Thiazide/thiazide-like diuretics
  • ACE inhibitors (e.g., lisinopril)
  • ARBs (e.g., losartan)
  • Long-acting dihydropyridine calcium channel blockers

• Starting doses should be low to moderate (e.g., losartan 50 mg daily, lisinopril 10 mg daily) and can be titrated up based on blood pressure response 2, 3

Combination Therapy Approach

• Combination therapy, preferably as a single pill combination to improve adherence, is suggested as an initial treatment approach 1, 4
• Combinations should include drugs from the following classes 1:
  • Thiazide/thiazide-like diuretics
  • ACEIs or ARBs (not both together)
  • Long-acting dihydropyridine calcium channel blockers

Special Population Considerations

• For Black patients, a calcium channel blocker or thiazide/thiazide-like diuretic may be more effective as initial therapy 1, 5
• For patients with specific comorbidities, certain drug classes may be preferred 1:
  • Chronic kidney disease: ACEI or ARB
  • Diabetes with albuminuria: ACEI or ARB
  • Heart failure with reduced ejection fraction: ACEI/ARB, beta-blockers
  • Stable ischemic heart disease: Beta-blockers, ACEI or ARB

Treatment Targets

• For patients without comorbidities: target BP <140/90 mmHg 1
• For patients with known cardiovascular disease: target SBP <130 mmHg 1
• For high-risk patients (high CVD risk, diabetes, chronic kidney disease): target SBP <130 mmHg 1
• Maintain diastolic BP between 70-80 mmHg, as values <60 mmHg may increase cardiovascular risk 1

Follow-Up and Monitoring

• Monthly follow-up after initiation or change in antihypertensive medications until target BP is reached 1
• Follow-up every 3-5 months for patients with controlled BP 1
• Laboratory testing to screen for comorbidities is suggested when starting therapy, but should not delay treatment initiation 1

Stepwise Approach for Inadequate Response

If initial therapy does not achieve target BP:

1. Optimize the dose of the initial agent before adding additional medications 4
2. Add a second agent from a different recommended class 4
3. Add a third agent from the remaining recommended class if needed 4
4. For resistant hypertension, consider adding spironolactone as a fourth-line agent 4

Common Pitfalls to Avoid

• Not checking medication adherence before adding or changing medications 4
• Inadequate dosing before adding new agents 4
• Not allowing sufficient time (2-4 weeks) for full medication effect before making changes 4
• Using immediate-release nifedipine or hydralazine as initial therapy 1, 6
• Failing to consider patient-specific contraindications (e.g., ACEIs/ARBs in pregnancy, thiazides in gout) 1