What is the initial treatment approach for hypertension?

Initial Treatment Approach for Hypertension

For patients with hypertension, the initial treatment should include lifestyle modifications along with pharmacological therapy, with the specific medication regimen determined by the severity of hypertension.

Diagnosis and Classification

• Hypertension is defined as office BP ≥140/90 mmHg, confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 1
• Initial evaluation should include measurement of BP in both arms, using the arm with higher readings for subsequent measurements 1

Lifestyle Modifications

Lifestyle modifications should be implemented for all patients with hypertension:

• Follow a DASH-style eating pattern including reduced sodium (<2,300 mg/day) and increased potassium intake 2
• Engage in regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) 2
• Achieve and maintain a healthy weight (BMI 20-25 kg/m²) 3
• Moderate alcohol consumption (no more than 2 drinks/day for men, 1 drink/day for women) 2
• Smoking cessation 3

Pharmacological Therapy

Initial Drug Selection

• For patients with BP between 130/80 mmHg and 150/90 mmHg, begin with a single antihypertensive medication 2
• For patients with BP ≥150/90 mmHg, initiate treatment with two antihypertensive medications 2
• First-line medication options include:
  • ACE inhibitors (e.g., lisinopril) 2, 4
  • ARBs (e.g., losartan) 2, 5
  • Thiazide-like diuretics 2
  • Dihydropyridine calcium channel blockers 2

Special Populations

• For patients with albuminuria (UACR ≥30 mg/g), initial treatment should include an ACE inhibitor or ARB 2
• For patients with established coronary artery disease, ACE inhibitors or ARBs are recommended as first-line therapy 2
• For Black patients, consider starting with ARB + dihydropyridine CCB or CCB + thiazide-like diuretic 2, 3

Treatment Algorithm

1. For BP 130/80-150/90 mmHg:

   • Start with a single agent: ACE inhibitor, ARB, thiazide-like diuretic, or calcium channel blocker 2
   • Initial dose for lisinopril: 10 mg once daily 4
   • Initial dose for losartan: 50 mg once daily 5

2. For BP ≥150/90 mmHg:

   • Start with two-drug combination 2
   • Preferred combinations include:
     • ACE inhibitor or ARB + calcium channel blocker
     • ACE inhibitor or ARB + thiazide-like diuretic 3

3. If BP target not achieved:

   • Increase to full dose of initial medication(s) 2
   • Add a third agent from a different class if needed 2

Monitoring and Follow-up

• Check serum creatinine and potassium 7-14 days after initiation or dose changes of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2
• Monitor for hypokalemia when diuretics are used 2
• Aim to achieve BP target within 3 months 1
• Target BP should be <130/80 mmHg for most adults 1

Common Pitfalls to Avoid

• Avoid ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors in pregnant women or women planning pregnancy 2
• Avoid combination of two RAS blockers (such as ACE inhibitor + ARB) as this can increase adverse effects 3
• Do not delay pharmacological therapy in high-risk patients (those with CVD, CKD, diabetes, or target organ damage) 3
• Single-pill combinations may improve medication adherence and should be considered when appropriate 2

Evidence Quality Considerations

The most recent and highest quality evidence comes from the 2025 Diabetes Care guidelines 2, which provide comprehensive recommendations for hypertension management. These guidelines align with other major society recommendations but provide the most up-to-date guidance on initial treatment approaches.