What is the recommended treatment for a 43-year-old female patient with elevated blood pressure (hypertension) and a QT interval of 392 ms?

Treatment for 43-Year-Old Female with Hypertension (BP 142/94)

This patient requires immediate initiation of combination antihypertensive therapy with a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide diuretic, preferably as a fixed-dose single-pill combination, along with lifestyle modifications. 1

Blood Pressure Classification and Treatment Urgency

• This patient has confirmed hypertension with BP ≥140/90 mmHg, which mandates prompt initiation of both lifestyle measures and pharmacological BP-lowering treatment to reduce cardiovascular disease risk. 1
• The target systolic BP should be 120-129 mmHg, provided treatment is well tolerated, to optimally reduce cardiovascular outcomes. 1

Initial Pharmacological Treatment Approach

Combination therapy is strongly preferred over monotherapy:

• Combination BP-lowering treatment is recommended as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg), as trial evidence demonstrates more effective BP control versus monotherapy. 1
• The preferred combinations are a RAS blocker (either an ACE inhibitor or ARB) with a dihydropyridine calcium channel blocker OR a RAS blocker with a thiazide/thiazide-like diuretic. 1
• Fixed-dose single-pill combination treatment is specifically recommended to improve adherence. 1

Specific first-line drug classes with proven efficacy:

• ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and thiazide/thiazide-like diuretics (such as chlorthalidone and indapamide) have demonstrated the most effective reduction of BP and cardiovascular events. 1

Practical Medication Options

Option 1: ARB + Thiazide Diuretic

• Start with telmisartan 40 mg plus hydrochlorothiazide 12.5 mg as a fixed-dose combination, which is commercially available and provides significantly greater BP reduction than monotherapy. 2
• Alternatively, losartan 50 mg can be used as the ARB component. 3

Option 2: ACE Inhibitor + Calcium Channel Blocker

• Lisinopril combined with a dihydropyridine calcium channel blocker (such as amlodipine) represents another evidence-based first-line combination. 4

QT Interval Considerations

• The QT interval of 392 ms is within normal limits for this patient and does not contraindicate any first-line antihypertensive medications. 1
• Standard antihypertensive agents (ACE inhibitors, ARBs, calcium channel blockers, thiazide diuretics) do not significantly prolong the QT interval and are safe to use. 1

Escalation Strategy if BP Remains Uncontrolled

If BP is not controlled with two-drug combination:

• Increase to a three-drug combination, usually a RAS blocker with a dihydropyridine calcium channel blocker AND a thiazide/thiazide-like diuretic, preferably in a single-pill combination. 1
• For example, if starting with telmisartan 40 mg plus hydrochlorothiazide 12.5 mg, the telmisartan dose can be increased to 80 mg while maintaining hydrochlorothiazide at 12.5 mg. 2

Important caveat: Higher doses of hydrochlorothiazide (>25 mg) add little additional antihypertensive efficacy but increase the risk of adverse effects such as hypokalemia. 2

Essential Lifestyle Modifications

• Restrict free sugar consumption to maximum 10% of energy intake and discourage sugar-sweetened beverages. 1
• Stop tobacco smoking if applicable, with referral to smoking cessation programs. 1
• Preferably avoid alcohol consumption to achieve best health outcomes. 1
• Sodium restriction and weight management through dietary approaches should be implemented. 1

Monitoring and Follow-up

• Assess BP response within 4-6 weeks after initiating therapy. 5
• Monitor for electrolyte disturbances, particularly hypokalemia, when using thiazide diuretics. 2
• Medications should be taken at the most convenient time of day to establish a habitual pattern and improve adherence. 1
• BP-lowering drug treatment should be maintained lifelong if well tolerated. 1

Critical Pitfall to Avoid

Never combine two RAS blockers (ACE inhibitor AND ARB together) - this combination is specifically not recommended due to lack of additional benefit and increased risk of adverse effects. 1