What are the initial treatment recommendations for managing hypertension?

Initial Treatment Recommendations for Managing Hypertension

For most adults with hypertension, initial treatment should include a two-drug combination of a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic for patients with BP ≥140/90 mmHg. 1, 2

Diagnosis and Blood Pressure Targets

• 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) 2
• For most adults, the recommended BP target is 120-129/<80 mmHg, provided treatment is well tolerated 1
• For older patients (≥65 years), a systolic BP target range of 130-139 mmHg is recommended 1

Initial Pharmacological Treatment Algorithm

Step 1: Lifestyle Modifications

• Implement weight loss if overweight/obese 1, 3
• Adopt a Mediterranean or DASH eating pattern with reduced sodium intake 1, 4
• Regular physical activity (at least 150 minutes of moderate-intensity exercise per week) 1, 5
• Limit alcohol consumption (≤14 units/week for men, ≤8 units/week for women) 1, 6
• Increase consumption of fruits, vegetables, and low-fat dairy products 3, 6

Step 2: Pharmacological Therapy

• For BP 140-159/90-99 mmHg: Consider starting with a single agent, preferably a RAS blocker (ACE inhibitor or ARB), thiazide-like diuretic, or calcium channel blocker 1
• For BP ≥160/100 mmHg: Start with a two-drug combination 1
  • Preferred combination: RAS blocker + calcium channel blocker or thiazide/thiazide-like diuretic 1, 2
  • For Black patients: Initial treatment should include a diuretic or calcium channel blocker, either alone or in combination with a RAS blocker 1

Special Populations

Diabetes

• For patients with diabetes, ACE inhibitors or ARBs are recommended as first-line therapy 1, 2
• Target BP is 130-139 mmHg systolic for patients with diabetic CKD 1

Chronic Kidney Disease

• For patients with albuminuria (UACR ≥30 mg/g), initial treatment should include an ACE inhibitor or ARB 1
• For moderate-to-severe CKD with eGFR >30 mL/min/1.73m², target systolic BP of 120-129 mmHg is recommended 1, 2

Heart Failure

• For patients with heart failure, treatment should include an ACE inhibitor or ARB, beta-blocker, and diuretic and/or mineralocorticoid receptor antagonist if required 1

Management of Resistant Hypertension

Resistant hypertension is defined as BP ≥140/90 mmHg despite appropriate lifestyle management plus a diuretic and two other antihypertensive drugs at adequate doses 1, 7.

• Add spironolactone (mineralocorticoid receptor antagonist) to existing treatment 1
• If spironolactone is not tolerated, consider eplerenone, higher-dose thiazide/thiazide-like diuretic, loop diuretic, or addition of bisoprolol or doxazosin 1, 7
• Monitor serum creatinine and potassium when using mineralocorticoid receptor antagonists with ACE inhibitors or ARBs due to increased risk of hyperkalemia 1

Medication Dosing Considerations

• ACE inhibitors (e.g., lisinopril): Start at 10 mg once daily, with usual dosage range of 20-40 mg per day 8
• ARBs (e.g., losartan): Start at 50 mg once daily, can increase to maximum of 100 mg once daily as needed 9
• If adding a diuretic to lisinopril, consider reducing the lisinopril dose to 5 mg once daily initially 8

Common Pitfalls and Caveats

• Avoid using ACE inhibitors and ARBs together as this increases risk of adverse effects without additional benefit 1
• Monitor renal function and electrolytes after initiating RAS blockers, especially in patients with CKD 2
• Consider white coat hypertension, medication nonadherence, and secondary causes before diagnosing resistant hypertension 1, 7
• Single-pill combinations may improve medication adherence 1
• Bedtime dosing of antihypertensives is not specifically recommended based on recent evidence 1

Following this structured approach to hypertension management will help achieve optimal blood pressure control and reduce cardiovascular morbidity and mortality in patients with hypertension.