What are the initial treatment guidelines for hypertension?

Initial Treatment Guidelines for Hypertension

For most adults with newly diagnosed hypertension, start combination therapy immediately with an ACE inhibitor or ARB plus either a calcium channel blocker or thiazide-like diuretic, targeting BP <130/80 mmHg to be achieved within 3 months. 1

Diagnosis and Confirmation

• Confirm hypertension using validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms and using the higher reading 2, 1
• Office BP ≥140/90 mmHg defines hypertension, but must be confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 2, 1
• Assess for target organ damage, cardiovascular risk factors, diabetes, chronic kidney disease, and secondary causes of hypertension 1

Lifestyle Modifications (Start Immediately for All Patients)

All patients require lifestyle interventions regardless of whether drug therapy is initiated: 2, 1

• Dietary changes: Implement DASH or Mediterranean diet with reduced sodium intake (<2.3g/day), increased potassium, and low-fat dairy products 1, 3
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly plus resistance training 2-3 times per week 1
• Weight management: Target BMI 20-25 kg/m² with healthy waist circumference 1, 3
• Alcohol moderation: Limit to <100g/week of pure alcohol or preferably complete avoidance 1
• Smoking cessation: Complete cessation with appropriate support 1

When to Start Drug Therapy

Grade 2 Hypertension (≥160/100 mmHg)

• Start drug therapy immediately along with lifestyle modifications regardless of cardiovascular risk 2, 1

Grade 1 Hypertension (140-159/90-99 mmHg)

• Start drug therapy immediately if: High-risk patients with established CVD, CKD, diabetes, target organ damage, or aged 50-80 years 2, 1
• Start drug therapy after 3-6 months of lifestyle intervention if: Low-moderate risk patients with persistent BP elevation 2

Elevated BP (130-139/80-89 mmHg)

• Start drug therapy immediately if high cardiovascular risk (established CVD, CKD, diabetes, target organ damage) 1

Initial Drug Selection Algorithm

Non-Black Patients

Preferred initial approach: Two-drug combination therapy as single-pill combination 1

1. First-line: Low-dose ACE inhibitor or ARB + dihydropyridine calcium channel blocker 2, 1
   • Alternative: ACE inhibitor or ARB + thiazide-like diuretic 1
2. If BP not controlled: Increase to full dose 2
3. If still not controlled: Add thiazide-like diuretic (creating three-drug combination) 2, 1
4. Resistant hypertension: Add spironolactone or, if not tolerated/contraindicated, amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 2, 1

Black Patients

Preferred initial approach: 2, 1

1. First-line: Low-dose ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic 2, 1
2. If BP not controlled: Increase to full dose 2
3. If still not controlled: Add diuretic or ACE inhibitor/ARB 2
4. Resistant hypertension: Add spironolactone or alternatives as above 2

Special Considerations for Monotherapy

• Consider monotherapy only for: Low-risk grade 1 hypertension, patients >80 years, or frail patients 2, 1

Specific First-Line Medications

ACE Inhibitors: Lisinopril starting dose 10 mg once daily, usual range 20-40 mg daily 4, 3

ARBs: Losartan starting dose 50 mg once daily, can increase to 100 mg daily 5, 3

Calcium Channel Blockers: Amlodipine (dihydropyridine) for hypertension 6, 3

Thiazide-like Diuretics: Chlorthalidone preferred over hydrochlorothiazide based on trial data 3, 7

Blood Pressure Targets

• Most adults <65 years: <130/80 mmHg 1, 3
• Adults 65-85 years: Systolic BP 120-129 mmHg if well tolerated 1
• Adults >85 years: Systolic BP 130-139 mmHg if well tolerated, individualized based on frailty 2, 1
• Patients with diabetes, CKD, or established CVD: <130/80 mmHg 2, 1
• Initial goal: Reduce BP by at least 20/10 mmHg 2

Monitoring and Follow-Up

• Achieve target BP within 3 months of initiating treatment 2, 1
• Schedule follow-up within 2-4 weeks initially to assess response and tolerability 8
• Check serum creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Implement home BP monitoring to guide medication adjustments and improve adherence 1, 8
• Schedule monthly visits until BP target achieved 1

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB) as this is potentially harmful 1
• Avoid clinical inertia: The 2020 ISH guidelines emphasize immediate combination therapy rather than sequential monotherapy titration, which is more effective 2, 1
• Do not discontinue lifestyle modifications once drug therapy starts—they are complementary and may reduce medication requirements 2, 1
• For patients with possible intravascular depletion (on diuretics), start ARBs at lower doses (losartan 25 mg) 5

When to Refer

• Refer to hypertension specialist if BP remains uncontrolled on 3 medications at optimal doses 1, 8
• Consider referral for suspected secondary hypertension: young age (<30 years requiring treatment), sudden onset/worsening, resistant to multidrug regimen, hypokalemia with high-normal sodium, elevated creatinine, or proteinuria/hematuria 2

Urgent Treatment Situations

Immediate intervention required for: 2

• Accelerated hypertension (severe hypertension with grade III-IV retinopathy)
• Particularly severe hypertension (>220/120 mmHg)
• Impending complications (transient ischemic attack, left ventricular failure)