What is the first line in treating hypertension?

First-Line Treatment for Hypertension

The first-line treatment for hypertension consists of lifestyle modifications for all patients with BP >120/80 mmHg, combined with pharmacological therapy using one of four medication classes—thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, or calcium channel blockers—for patients meeting treatment thresholds. 1, 2

Treatment Initiation Thresholds

Lifestyle modifications should be started immediately for all patients with BP >120/80 mmHg. 1, 2

Pharmacological therapy should be initiated when:

• BP is ≥140/90 mmHg in most patients 3
• BP is ≥130/80 mmHg in high-risk patients (those with established CVD, diabetes, or chronic kidney disease) 1, 2

Lifestyle Modifications (Foundation for All Patients)

All patients require the following interventions: 1, 2, 4

• Weight loss: Achieve and maintain healthy body weight through caloric restriction if overweight or obese 2, 4
• DASH diet: Adopt Dietary Approaches to Stop Hypertension eating pattern with sodium <2,300 mg/day and increased potassium intake 1, 2
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise per week 1, 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 2
• Smoking cessation: Complete cessation for all patients 2, 5

These lifestyle modifications have additive BP-lowering effects and enhance the efficacy of pharmacological therapy. 4

First-Line Pharmacological Therapy

The four first-line medication classes are equally effective and should be selected based on patient characteristics: 3, 1, 2

Standard First-Line Options:

• Thiazide or thiazide-like diuretics (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1, 2, 4
• ACE inhibitors (e.g., lisinopril, enalapril) 1, 2, 4
• Angiotensin receptor blockers (ARBs) (e.g., candesartan) 1, 2, 4
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2, 4

Initial Dosing Strategy Based on BP Severity

For BP 130/80-150/90 mmHg: Start with a single agent from one of the four first-line classes. 1, 2

For BP ≥150/90 mmHg: Initiate treatment with two antihypertensive medications simultaneously, preferably as a single-pill combination to improve adherence. 1, 2

Special Population Considerations

Black Patients:

Calcium channel blockers or thiazide diuretics are more effective than ACE inhibitors or ARBs as monotherapy. 3, 1

When combination therapy is needed: Use CCB plus thiazide-like diuretic OR CCB plus ARB. 1

Patients with Albuminuria (UACR ≥30 mg/g):

ACE inhibitor or ARB is the mandatory first-line choice because these agents reduce albuminuria in addition to lowering BP. 3, 2

Patients with Coronary Artery Disease:

ACE inhibitor or ARB should be selected as first-line therapy. 2

Patients with Chronic Kidney Disease:

RAS inhibitors (ACE inhibitors or ARBs) are first-line drugs because they reduce albuminuria and slow CKD progression. 3 CCBs and diuretics (loop diuretics if eGFR <30 mL/min/1.73m²) can be added. 3

Patients with Heart Failure:

For HFrEF: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists are all effective. 3 CCBs are indicated only for poor BP control. 3

Patients with Previous Stroke:

RAS blockers, CCBs, and diuretics are first-line drugs. 3

Blood Pressure Targets

Target BP <130/80 mmHg for most adults <65 years. 1, 4

Target SBP <130 mmHg for adults ≥65 years. 4

Target <140/80 mmHg in elderly patients based on frailty considerations. 3, 1

Critical Monitoring Requirements

Monitor serum creatinine and potassium levels when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 1, 2

Follow-up 7-14 days after medication initiation or dose changes. 1, 2

Goal: Achieve BP target within 3 months. 1

Important Caveats

Never combine ACE inhibitors with ARBs—this increases adverse effects without additional benefit. 1, 2

ACE inhibitors, ARBs, and related agents are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential not using reliable contraception. 2

Single-pill combinations improve medication adherence and should be considered when initiating two-drug therapy. 1, 2

A 10 mmHg reduction in SBP decreases CVD events by approximately 20-30%, emphasizing the importance of achieving target BP. 4