What is the initial treatment for a patient with stage 2 hypertension?

Initial Treatment for Blood Pressure 158/98

Start combination therapy with two antihypertensive agents from different classes—specifically a thiazide-type diuretic (chlorthalidone 12.5 mg or hydrochlorothiazide 25 mg) plus either an ACE inhibitor (lisinopril 10 mg) or calcium channel blocker (amlodipine 5 mg)—and initiate lifestyle modifications simultaneously. 1

Rationale for Two-Drug Initiation

This blood pressure of 158/98 mmHg represents Stage 2 hypertension (systolic ≥140 mmHg or diastolic ≥90 mmHg). 1

• Two-drug combination therapy is the standard approach for Stage 2 hypertension, particularly when BP is >20/10 mmHg above target (target is <130/80 mmHg for most adults). 1
• Starting with two agents achieves BP control faster, improves adherence when using single-pill combinations, and reduces cardiovascular risk more rapidly than sequential monotherapy titration. 1, 2
• The patient should be evaluated within 1 month and have BP rechecked to assess response. 1

Specific Drug Recommendations

First-Line Combination Options:

Option 1 (Preferred): Thiazide-type diuretic + ACE inhibitor

• Chlorthalidone 12.5-25 mg daily PLUS lisinopril 10 mg daily 1, 3
• Chlorthalidone is preferred over hydrochlorothiazide due to longer half-life and superior CVD outcome data 1, 2

Option 2: Thiazide-type diuretic + Calcium channel blocker

• Chlorthalidone 12.5-25 mg daily PLUS amlodipine 5 mg daily 1, 2

Option 3: ACE inhibitor + Calcium channel blocker

• Lisinopril 10 mg daily PLUS amlodipine 5 mg daily 2

Why These Drug Classes:

• Thiazide diuretics (especially chlorthalidone) have the strongest evidence for reducing cardiovascular events, stroke, and heart failure compared to other first-line agents. 1, 4
• ACE inhibitors are highly effective, well-tolerated, and particularly beneficial if the patient has diabetes, chronic kidney disease, or coronary artery disease. 1, 5, 6
• Calcium channel blockers (dihydropyridine type like amlodipine) are equally effective and particularly useful in Black patients or those who cannot tolerate ACE inhibitors. 1, 5, 6

Special Considerations Before Starting

Check for contraindications:

• Pregnancy or planning pregnancy: Absolutely avoid ACE inhibitors and ARBs (use calcium channel blockers or methyldopa instead). 2
• History of angioedema: Avoid ACE inhibitors. 1
• Gout or history of acute gout: Use thiazides cautiously unless on uric acid-lowering therapy. 1
• Severe bilateral renal artery stenosis: Avoid ACE inhibitors/ARBs due to acute renal failure risk. 1

Baseline laboratory monitoring:

• Obtain serum creatinine, electrolytes (sodium, potassium), and estimated GFR before starting therapy. 1, 2
• Recheck these labs 2-4 weeks after initiation to monitor for hyperkalemia (with ACE inhibitors) or hypokalemia (with diuretics). 1, 2

Critical Pitfalls to Avoid

• Do NOT delay pharmacotherapy for a trial of lifestyle modification alone at this BP level—both should be started simultaneously. 1, 2
• Do NOT start with monotherapy in Stage 2 hypertension, as most patients will require multiple agents anyway and this delays BP control. 1
• Do NOT use beta-blockers as first-line unless there is a compelling indication (heart failure, post-MI, coronary disease), as they are less effective for stroke prevention. 1, 2
• Avoid starting ACE inhibitors at full dose in elderly patients or those at risk for hypotension—use lower starting doses (lisinopril 5 mg or 2.5 mg if volume depleted). 3, 7
• Monitor for first-dose hypotension with ACE inhibitors, especially in patients on diuretics, elderly patients, or those with heart failure—observe for at least 6 hours after first dose in high-risk patients. 7

Lifestyle Modifications (Concurrent with Medications)

Implement all of the following simultaneously with drug therapy: 2, 5

• DASH diet: 8-10 servings of fruits/vegetables daily, 2-3 servings low-fat dairy 2
• Sodium restriction: <2,300 mg/day 2
• Weight loss if overweight (target BMI <25) 2
• Physical activity: ≥150 minutes moderate-intensity aerobic exercise weekly 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 2
• Smoking cessation if applicable 2

Follow-Up Strategy

• Recheck BP in 1 month after initiating therapy. 1
• If BP remains >130/80 mmHg, increase doses of current medications to maximum tolerated before adding a third agent. 2
• If BP still uncontrolled on two drugs at optimal doses, add a third agent from a different class (typically the missing drug from the thiazide/ACE inhibitor/calcium channel blocker triad). 2
• Target BP: <130/80 mmHg for most adults under 65 years; <130 mmHg systolic for those ≥65 years. 1, 2