What are the first-line treatment options for managing hypertension?

First-Line Treatment Options for Managing Hypertension

The first-line treatment options for hypertension include thiazide or thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs), with medication selection guided by patient-specific factors such as comorbidities. 1, 2, 3

Initial Approach to Treatment

• All patients with blood pressure >120/80 mmHg should begin with lifestyle modifications including weight loss when indicated, DASH diet, sodium restriction (<2,300 mg/day), increased potassium intake, physical activity, smoking cessation, and limited alcohol consumption 1
• Lifestyle modifications can lower blood pressure and enhance the effectiveness of pharmacological therapy 1, 3
• For patients with blood pressure 130/80-159/99 mmHg, begin with a single antihypertensive agent 1, 2
• For patients with blood pressure ≥160/100 mmHg, initiate treatment with two antihypertensive medications or a single-pill combination 1, 2

First-Line Medication Classes

• Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide) 1, 2, 3
• ACE inhibitors (e.g., enalapril, lisinopril) 1, 2, 3
• ARBs (e.g., losartan, candesartan) 1, 2, 3
• Calcium channel blockers (e.g., amlodipine) 1, 2, 3

Medication Selection Based on Patient Characteristics

• For Black patients, CCBs or thiazide diuretics are more effective as initial therapy compared to ACE inhibitors 2
• For patients with diabetes and albuminuria, ACE inhibitors or ARBs are recommended as first-line therapy 1, 2
• For patients with coronary artery disease, ACE inhibitors or ARBs are preferred first-line agents 1, 2
• For patients with chronic kidney disease and albuminuria (UACR ≥30 mg/g), ACE inhibitors or ARBs are strongly recommended 1, 2
• For patients with heart failure, RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists are effective in improving clinical outcomes 4

Combination Therapy Approach

• Multiple-drug therapy is generally required to achieve blood pressure targets of <130/80 mmHg 4, 1
• For resistant hypertension (BP ≥140/90 mmHg despite three medications including a diuretic), consider adding a mineralocorticoid receptor antagonist 4, 1, 5
• Avoid combinations of ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 1

Monitoring and Follow-up

• For patients on ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium levels at least annually 1
• More frequent monitoring (7-14 days) is recommended after initiation or dose changes of these medications 1
• Assess medication adherence regularly, as non-adherence is a common cause of uncontrolled hypertension 4

Evidence on Comparative Effectiveness

• First-line thiazide diuretics have shown superior outcomes in preventing heart failure compared to CCBs and ACE inhibitors 2, 6
• CCBs are as effective as diuretics for reducing all cardiovascular events except heart failure 2
• Chlorthalidone has the highest-level evidence supporting its efficacy from three large comparative clinical trials 6
• An SBP reduction of 10 mm Hg decreases risk of CVD events by approximately 20% to 30% 3

Common Pitfalls to Avoid

• Delaying initiation of pharmacological therapy in patients with significantly elevated blood pressure 1
• Using beta-blockers as first-line therapy in uncomplicated hypertension (they are indicated for patients with prior MI, active angina, or heart failure) 1, 2
• Combining ACE inhibitors with ARBs 1
• Inadequate monitoring of renal function and electrolytes in patients on ACE inhibitors, ARBs, or diuretics 1
• Failing to recognize and address medication adherence issues in patients with uncontrolled hypertension 4