What is the initial management of Hypertension (HTN)?

Initial Management of Hypertension

For adults with confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications AND pharmacological therapy simultaneously with a two-drug combination of a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1, 2

Confirming the Diagnosis

• Confirm hypertension using out-of-office measurements before initiating treatment: home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg) 1, 2
• Measure BP in both arms at the first visit and use the arm with higher readings for subsequent measurements 2
• Use validated automated upper arm cuff devices with appropriate cuff size 2

Lifestyle Modifications (Initiated Concurrently with Medications)

All patients require intensive lifestyle interventions alongside pharmacotherapy: 1, 3

• Weight loss through caloric restriction for overweight individuals 3
• DASH diet pattern emphasizing fruits and vegetables (8-10 servings/day), low-fat dairy (2-3 servings/day) 1, 3
• Sodium restriction to <2,300 mg/day 3
• Increased potassium intake through dietary sources 3
• Physical activity: at least 150 minutes of moderate-intensity aerobic exercise weekly 3
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 3
• Smoking cessation 3

Important caveat: While lifestyle changes are crucial, the 2024 ESC guidelines explicitly reject the older approach of delaying pharmacotherapy for 3-6 months to "try lifestyle first" in patients with BP ≥140/90 mmHg. 1, 3

Initial Pharmacological Therapy

Standard Two-Drug Combination Approach

For most patients with BP ≥140/90 mmHg, start with two medications: 1, 2

• Preferred combination: RAS blocker (ACE inhibitor OR ARB) + dihydropyridine calcium channel blocker 1
• Alternative combination: RAS blocker + thiazide/thiazide-like diuretic 1
• Strongly prefer single-pill combinations to improve adherence 1, 3

Specific dosing examples from FDA labels:

• Lisinopril 10 mg daily (can titrate to 20-40 mg) 4 + Amlodipine 5 mg daily
• Losartan 50 mg daily (can titrate to 100 mg) 5 + Hydrochlorothiazide 12.5-25 mg daily 6

Race-Based Considerations

For Black patients, initial therapy should be: 2

• ARB + dihydropyridine calcium channel blocker, OR
• Calcium channel blocker + thiazide/thiazide-like diuretic

Rationale: Black patients may have reduced response to ACE inhibitors as monotherapy, though this is less relevant when using combination therapy 1

Exceptions to Two-Drug Start

Start with single-agent therapy only in: 1, 3

• Patients aged ≥85 years
• Those with symptomatic orthostatic hypotension
• Moderate-to-severe frailty
• Elevated BP (120-139/70-89 mmHg) with high cardiovascular risk

Blood Pressure Targets

Target BP <130/80 mmHg for most adults under 65 years 2, 7

For adults 65-85 years: Target systolic BP 120-129 mmHg if well tolerated 2

For patients with diabetes or CKD (eGFR >30 mL/min/1.73m²): Target systolic BP 120-129 mmHg 2

Special Population Considerations

Patients with Comorbidities

Diabetes or CKD with albuminuria (UACR ≥30 mg/g): Must include ACE inhibitor or ARB in initial regimen 2, 3

Heart failure: Include ACE inhibitor or ARB, beta-blocker, and mineralocorticoid receptor antagonist 2

Coronary artery disease: Prefer ACE inhibitor or ARB as first-line 3

Pregnancy Considerations

Absolutely contraindicated in pregnancy or women planning pregnancy: 1, 3

• ACE inhibitors
• ARBs
• Mineralocorticoid receptor antagonists
• Direct renin inhibitors

These agents cause fetal injury and death 1

Titration and Follow-Up Strategy

Achieve BP control within 3 months: 1, 2

• See patients every 1-3 months until BP controlled 1
• If BP not controlled with two drugs: Escalate to three-drug combination (RAS blocker + calcium channel blocker + thiazide diuretic) 1
• If BP not controlled with three drugs: Add spironolactone 25 mg daily 1
• Monitor labs (creatinine, potassium) 7-14 days after starting or adjusting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2, 3

Titration Algorithm

1. Start two-drug combination at standard doses 1
2. If inadequate response at 2-4 weeks, increase to full doses 3
3. If still inadequate, add third agent (thiazide diuretic if not already included) 1
4. If resistant to three drugs, add spironolactone 1
5. Fifth-line options: beta-blocker, alpha-blocker, or centrally acting agent 1

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

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for lifestyle modification trial in patients with BP ≥140/90 mmHg 1, 3
• Do not start with monotherapy in most patients with BP ≥140/90 mmHg (outdated approach) 1
• Do not use hydrochlorothiazide when chlorthalidone or indapamide are available (longer-acting thiazide-like diuretics preferred) 1
• Do not use beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease) 1
• Do not withhold treatment due to asymptomatic orthostatic hypotension - this does not increase adverse events 1