What treatment options are available for a patient with hypertension (high blood pressure) who is not currently taking any blood pressure (BP) medication and has a blood pressure reading of 150/100 mmHg?

Treatment for Blood Pressure 150/100 mmHg (Treatment-Naïve Patient)

Start immediate pharmacologic treatment with two antihypertensive medications, as this blood pressure reading (150/100 mmHg) qualifies as Grade 2 hypertension (≥150/90 mmHg), which requires dual therapy from the outset to achieve blood pressure control within 3 months. 1, 2

Initial Pharmacologic Approach

For Non-Black Patients:

• Start with an ACE inhibitor (such as lisinopril 10 mg daily) plus a thiazide-like diuretic (such as chlorthalidone 12.5-25 mg daily) 1, 2, 3
• Alternative: ACE inhibitor plus a dihydropyridine calcium channel blocker (such as amlodipine 5 mg daily) 1, 4

For Black Patients:

• Start with an ARB (such as losartan 50 mg daily) plus a dihydropyridine calcium channel blocker (amlodipine 5 mg daily) 2, 5, 4
• Alternative: Dihydropyridine calcium channel blocker plus a thiazide-like diuretic 2

Rationale for Dual Therapy:

• Blood pressure ≥150/90 mmHg requires two medications initially to achieve target BP more effectively and rapidly 1
• Single-pill combination products may improve medication adherence 1
• Expected blood pressure reduction with dual therapy: approximately 15-20/9-10 mmHg 5

Blood Pressure Targets

• Primary target: <130/80 mmHg for most adults 1, 2, 6
• For adults ≥60 years without diabetes or chronic kidney disease: <150/90 mmHg is acceptable, though <140/90 mmHg provides additional stroke reduction 1
• Achieve target within 3 months of initiating therapy 2

Concurrent Lifestyle Modifications (Essential)

All patients with BP >120/80 mmHg require intensive lifestyle intervention alongside medications: 1

• Weight loss if overweight/obese through caloric restriction 1, 6
• DASH diet pattern: 8-10 servings of fruits/vegetables daily, 2-3 servings of low-fat dairy, reduced saturated fat 1, 7
• Sodium restriction to <2,300 mg/day 1, 6
• Increase potassium intake through dietary sources 1, 7
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly 1, 6
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1, 6
• Smoking cessation if applicable 1

Expected Impact of Lifestyle Changes:

• These modifications lower BP independently and enhance medication effectiveness 1, 7
• Effects are partially additive when multiple interventions are combined 6

Monitoring and Follow-Up

• Schedule follow-up within 2-4 weeks to assess treatment response and medication tolerance 2
• Monitor serum creatinine and potassium 7-14 days after starting ACE inhibitor or ARB 1
• Implement home blood pressure monitoring to track progress and improve adherence 2
• Confirm BP readings with multiple measurements using validated device with appropriate cuff size 2

Special Considerations

If Patient Has Diabetes:

• Preferred first-line agents: ACE inhibitor or ARB (regardless of albuminuria status for BP control) 1
• If albuminuria present (UACR ≥30 mg/g): ACE inhibitor or ARB is mandatory to reduce progressive kidney disease 1

If Patient Has Coronary Artery Disease:

• ACE inhibitor or ARB is first-line therapy 1

If Uncontrolled on Initial Dual Therapy:

• Add a third agent from a different class (typically the missing component from ACE inhibitor/ARB, calcium channel blocker, or thiazide-like diuretic) 1
• If still uncontrolled on three agents including a diuretic: consider adding mineralocorticoid receptor antagonist (spironolactone) 1
• Refer to hypertension specialist if resistant to multiple medications 2

Important Caveats

• Avoid ACE inhibitors and ARBs in women of childbearing potential not using reliable contraception (teratogenic) 1
• Thiazide-like diuretics (chlorthalidone, indapamide) are preferred over hydrochlorothiazide for cardiovascular event reduction 1
• Beta-blockers are NOT first-line agents unless patient has prior MI, active angina, or heart failure with reduced ejection fraction 1
• Black patients may have reduced response to ACE inhibitors/ARBs as monotherapy, hence the recommendation for combination with calcium channel blocker or diuretic 2, 3