What is the first-line treatment for hypertension?

First-Line Treatment for Hypertension

The first-line treatment for hypertension includes both lifestyle modifications and pharmacological therapy with ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, or thiazide/thiazide-like diuretics, with combination therapy recommended for most patients with confirmed hypertension (BP ≥140/90 mmHg) as initial therapy. 1, 2

Lifestyle Modifications

Lifestyle modifications are essential for all patients with elevated blood pressure and should include:

• Sodium restriction to approximately 2g per day (equivalent to about 5g of salt) 1
• Regular physical activity: moderate-intensity aerobic exercise of ≥150 min/week plus resistance training 2-3 times/week 1, 2
• Weight management targeting a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Adoption of healthy dietary patterns such as Mediterranean or DASH diets 1, 2, 3
• Alcohol limitation to less than 100g/week of pure alcohol, with complete avoidance preferred 1
• Smoking cessation 1, 2
• Restriction of free sugar consumption, particularly sugar-sweetened beverages 1

Pharmacological Therapy

First-Line Medication Classes

Four medication classes have demonstrated the most effective reduction of BP and cardiovascular disease events:

• ACE inhibitors (e.g., lisinopril) 1, 2, 4
• Angiotensin receptor blockers (ARBs) 1, 2
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2, 5
• Thiazide/thiazide-like diuretics (preferably long-acting agents like chlorthalidone and indapamide) 1, 2

Initial Treatment Strategy

• For most patients with confirmed hypertension (BP ≥140/90 mmHg): Combination BP-lowering treatment is recommended as initial therapy 1, 2
• Preferred combinations: A RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or diuretic 1
• Fixed-dose single-pill combinations are recommended to improve adherence 1

Special Populations and Considerations

• For patients with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB is recommended as first-line therapy 1, 2
• For patients with coronary artery disease: ACE inhibitor or ARB is recommended as first-line therapy 1, 2
• For patients requiring beta-blockers (e.g., for angina, post-MI, heart failure): Combine with any of the other major BP-lowering drug classes 1
• For black patients: Calcium channel blockers or thiazide diuretics may be more effective than ACE inhibitors or ARBs when used as monotherapy 2, 6

Treatment Algorithm

1. For all patients with elevated BP: Implement lifestyle modifications 1, 2, 7
2. For BP 130/80-139/89 mmHg with high CVD risk: After 3 months of lifestyle intervention, initiate pharmacological treatment 1, 2
3. For BP ≥140/90 mmHg: Promptly initiate both lifestyle measures and pharmacological treatment 1, 2
4. Initial pharmacological approach:
   • For most patients: Start with combination therapy (RAS blocker + CCB or diuretic) 1
   • Exceptions (consider monotherapy): Patients aged ≥85 years, those with symptomatic orthostatic hypotension, moderate-to-severe frailty 1
5. If BP not controlled with two-drug combination: Progress to a three-drug combination (RAS blocker + CCB + thiazide/thiazide-like diuretic), preferably as a single-pill combination 1
6. For resistant hypertension: Consider adding a mineralocorticoid receptor antagonist 1, 8

Important Caveats

• Never combine two RAS blockers (ACE inhibitor and ARB) due to increased risk of adverse effects without additional benefit 1, 2
• BP target: Aim for treated systolic BP values of 120-129 mmHg in most adults, if well tolerated 1
• Monitor kidney function and electrolytes when using ACE inhibitors, ARBs, or diuretics 1, 2
• Medication timing: Take medications at the most convenient time of day to establish a habitual pattern and improve adherence 1
• Lifelong treatment is recommended, even beyond age 85 if well tolerated 1

Effectiveness of Treatment

• An SBP reduction of 10 mmHg decreases risk of cardiovascular disease events by approximately 20-30% 6
• Comprehensive lifestyle interventions can substantially lower blood pressure, even in patients already on antihypertensive medication 3