What is the first-line pharmacological treatment for a smoker with newly diagnosed hypertension and no target organ damage?

Recommended Pharmacological Management

For this 45-year-old smoker with confirmed stage 2 hypertension (166/102 mmHg) and no target organ damage, the correct answer is D: ACE-Inhibitor and calcium channel blocker, as two-drug combination therapy is recommended for initial treatment when blood pressure is ≥160/100 mmHg.

Rationale for Two-Drug Combination Therapy

Initial pharmacologic treatment with two antihypertensive medications is recommended for individuals with blood pressure ≥150/90 mmHg to more effectively achieve adequate blood pressure control 1. This patient's BP of 166/102 mmHg clearly exceeds this threshold, placing him in stage 2 hypertension category.

• For stage 2 hypertension (≥160/100 mmHg), guidelines recommend a two-drug combination for most patients, typically consisting of a thiazide-type diuretic plus an ACE inhibitor, ARB, beta-blocker, or calcium channel blocker 2
• Single-pill antihypertensive combinations may improve medication adherence 1

Why ACE-Inhibitor Plus Calcium Channel Blocker

The combination of an ACE inhibitor and calcium channel blocker represents one of the preferred two-drug regimens for several reasons:

• Initial treatment should include any drug class demonstrated to reduce cardiovascular events in people with hypertension: ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers 1
• Thiazide or thiazide-type diuretics, calcium channel blockers, ACE inhibitors, and ARBs are recommended as initial drug choices based on their efficacy in reducing BP and documented benefit in reducing clinical outcomes 1
• The combination of a calcium channel blocker plus renin-angiotensin system blocker (ACE inhibitor or ARB) is specifically endorsed for patients requiring two-drug therapy 1

Why Not the Other Options

Option A (ACE-Inhibitor and beta-blocker): Beta-blockers are generally not recommended as first-line agents in patients without coronary heart disease or heart failure due to lesser benefit on stroke reduction compared with other recommended classes 1. This patient has no indication for beta-blocker therapy.

Option B (Calcium channel blocker alone): Monotherapy is insufficient for this patient. Single-drug therapy is only appropriate for patients within 10 mmHg above target 1, whereas this patient is 26-36 mmHg above the target of <140/90 mmHg (or <130/80 mmHg by more aggressive targets).

Option C (Thiazide diuretics alone): Again, monotherapy is inadequate for stage 2 hypertension. While thiazide-like diuretics are excellent first-line agents 1, this patient requires combination therapy from the outset.

Target Blood Pressure and Follow-up

• The target BP should be <140/90 mmHg for this younger patient (<60 years) 1
• More aggressive targets of <130/80 mmHg are recommended by some guidelines 2
• Patients initiating drug therapy should be followed approximately monthly for drug titration until BP is controlled 1
• Target BP control should be achieved within 3 months 2

Additional Considerations

• Smoking cessation counseling is critical, as cigarette smoking is a major modifiable cardiovascular risk factor that should be addressed alongside hypertension management 1
• Lifestyle modifications including sodium restriction, weight management if indicated, increased physical activity, and alcohol moderation should accompany pharmacological therapy 1
• If the ACE inhibitor is not tolerated (e.g., due to cough), an ARB may be substituted 1
• Monitor renal function and serum potassium levels when using ACE inhibitors 1