What are the initial treatment guidelines for hypertension?

Initial Treatment Guidelines for Hypertension

Start most non-Black adults with hypertension on two-drug combination therapy using a single-pill combination of a low-dose ACE inhibitor or ARB plus a dihydropyridine calcium channel blocker (such as lisinopril 10 mg or losartan 50 mg combined with amlodipine 5 mg). 1

Confirming the Diagnosis

Before initiating treatment, confirm hypertension properly:

• Use validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms and using the higher reading 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) 1
• Assess for target organ damage (left ventricular hypertrophy, retinopathy, proteinuria), cardiovascular risk factors, diabetes, chronic kidney disease, and secondary causes of hypertension 1, 2

Lifestyle Modifications (Foundation for All Patients)

Implement lifestyle interventions immediately for all patients, regardless of whether drug therapy is started:

• DASH or Mediterranean diet with reduced sodium intake (<2.3 g/day), increased potassium, and low-fat dairy products 1, 3, 4
• At least 150 minutes of moderate-intensity aerobic exercise weekly plus resistance training 2-3 times per week 1
• Weight loss if overweight, alcohol moderation, and smoking cessation 1, 3, 5

These modifications are complementary to drug therapy and may reduce medication requirements—never discontinue them once drug therapy starts. 1

Initial Pharmacological Treatment

For Non-Black Patients:

Start with two-drug combination therapy as a single-pill combination: 1

• First-line: Low-dose ACE inhibitor or ARB + dihydropyridine calcium channel blocker 1
• Specific dosing examples: Lisinopril 10 mg 6 or losartan 50 mg 7 combined with amlodipine 5-10 mg 8

For Black Patients:

Preferred initial approach is low-dose ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic 1

• Example: Losartan 50 mg 7 plus amlodipine 5-10 mg 8, or amlodipine plus hydrochlorothiazide 12.5 mg

For Severely Elevated BP (≥160/100 mmHg):

Start immediate drug treatment—this is Grade 2 Hypertension requiring prompt intervention 2

• Non-Black patients: Start with low-dose ACE inhibitor/ARB 2
• Black patients: Start with low-dose ARB plus dihydropyridine calcium channel blocker or calcium channel blocker plus thiazide-like diuretic 2

Blood Pressure Targets

Target BP <130/80 mmHg for most adults, including those with diabetes, chronic kidney disease, or established cardiovascular disease 1, 3

• Initial goal: Reduce BP by at least 20/10 mmHg 1, 2
• Achieve target BP within 3 months of initiating treatment 1, 2

Monitoring and Follow-Up

Schedule follow-up within 2-4 weeks initially to assess response and tolerability 1, 2

• 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 track progress and improve adherence 2
• If BP remains uncontrolled despite multiple medications, refer to a specialist with expertise in hypertension management 2

Critical Pitfalls to Avoid

Never combine two RAS blockers (ACE inhibitor + ARB) as this is potentially harmful 1

Avoid clinical inertia: immediate combination therapy is more effective than sequential monotherapy titration 1

• Starting with two drugs achieves target BP faster and more effectively than starting with one drug and adding another later 1

Do not discontinue lifestyle modifications once drug therapy starts—they are complementary and may reduce medication requirements 1

Always assess for secondary causes of hypertension, particularly with severe or resistant hypertension 2