What is the initial treatment for hypertension?

Initial Treatment for Elevated Blood Pressure

For confirmed hypertension (BP ≥140/90 mmHg), start both lifestyle modifications AND pharmacological therapy simultaneously—do not delay medication while waiting to see if lifestyle changes work. 1

Immediate Pharmacological Treatment

First-Line Medication Choice

• Begin with a two-drug combination as initial therapy for most patients with BP ≥140/90 mmHg, preferably as a single-pill combination to improve adherence 1
• The preferred combinations are:
  • ACE inhibitor (e.g., lisinopril 10 mg) + dihydropyridine calcium channel blocker (e.g., amlodipine) 1, 2
  • OR ACE inhibitor + thiazide/thiazide-like diuretic 1
  • ARB (e.g., losartan 50 mg) can substitute for ACE inhibitor if not tolerated 1, 3

Exceptions to Two-Drug Initial Therapy

• Consider monotherapy (single agent) only for: 1
  • Patients aged >80 years
  • Frail patients
  • Those with symptomatic orthostatic hypotension
  • Elevated BP (120-139/70-89 mmHg) with specific high-risk conditions

For Black Patients

• Start with ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic 1, 4
• ACE inhibitors are less effective as monotherapy in Black patients 1

Concurrent Lifestyle Modifications

While starting medication immediately, strongly emphasize these lifestyle changes (which may allow future medication reduction): 1, 5

• Sodium restriction to <2,300 mg/day 5, 6
• DASH eating pattern: 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy 5, 7
• Weight loss if overweight (caloric restriction targeting healthy BMI) 5, 6
• Physical activity: At least 150 minutes/week of moderate-intensity aerobic exercise 5, 7
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 5, 6
• Smoking cessation 5
• Increased potassium intake through dietary sources 5, 6

Treatment Escalation Algorithm

If BP Not Controlled on Two-Drug Combination

• Increase to three-drug combination: RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 1

If BP Not Controlled on Three-Drug Combination

• Add spironolactone (mineralocorticoid receptor antagonist) 1
• If spironolactone not tolerated or contraindicated, consider: eplerenone, beta-blocker, alpha-blocker, or centrally acting agent 1

What NOT to Do

• Never combine two RAS blockers (ACE inhibitor + ARB together)—this is contraindicated 1

Monitoring Requirements

• Check serum creatinine and potassium 7-14 days after starting ACE inhibitor, ARB, or diuretic 5, 7, 4
• Reassess BP within 1-3 months until controlled, ideally achieving target within 3 months 1
• Target BP: 120-129/70-80 mmHg for most adults if well tolerated 1, 5

Special Populations

Patients with Specific Comorbidities

• Coronary artery disease: ACE inhibitor or ARB preferred 5
• Albuminuria (UACR ≥30 mg/g) or chronic kidney disease: ACE inhibitor or ARB mandatory to reduce progressive kidney disease 5, 4
• Heart failure: Add beta-blocker to regimen 5

Contraindications

• Women of childbearing potential: Provide reproductive counseling before prescribing ACE inhibitors or ARBs—these are teratogenic and absolutely contraindicated in pregnancy 5, 7

Common Pitfalls to Avoid

• Do not delay pharmacological treatment for 3-6 months to "try lifestyle changes first" in patients with BP ≥140/90 mmHg—the 2024 ESC guidelines explicitly recommend simultaneous initiation 1, 5
• The older approach of waiting 3-6 months applies only to elevated BP (120-139/70-89 mmHg) in low-risk patients without high-risk conditions 1, 7
• Do not start with monotherapy and uptitrate slowly—current evidence favors starting with two-drug combinations for faster BP control and better outcomes 1
• Do not underdose: Lisinopril 10 mg is the recommended starting dose, with usual maintenance of 20-40 mg daily 2; losartan starts at 50 mg with increase to 100 mg as needed 3