What is the first line treatment for hypertension?

First-Line Treatment for Hypertension

For most adults with hypertension requiring pharmacological therapy, initiate treatment with one of four equally effective medication classes: thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, or calcium channel blockers, combined with lifestyle modifications. 1, 2

Treatment Algorithm Based on Blood Pressure Level and Risk

Stage 1 Hypertension (130-139/80-89 mmHg)

• Low cardiovascular risk (<10% 10-year ASCVD risk): Start with lifestyle modifications alone for 3-6 months before considering medication 3, 4
• High cardiovascular risk (≥10% 10-year ASCVD risk, diabetes, CKD, or established CVD): Initiate both lifestyle modifications AND pharmacological therapy immediately 3, 2

Stage 2 Hypertension (≥140/90 mmHg)

• Start with two antihypertensive medications from different classes immediately, combined with lifestyle modifications 3, 1
• Evaluate or refer to primary care within 1 month 3

Hypertensive Crisis (≥180/110 mmHg)

• Initiate prompt antihypertensive drug treatment within 1 week maximum, with rapidity dependent on presence of target organ damage 3

First-Line Medication Selection by Patient Characteristics

General Population (Non-Black Patients)

• Choose any of the four first-line classes: thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, or calcium channel blockers 1, 5
• These classes are equally effective for most patients 2
• Thiazide diuretics (particularly chlorthalidone) have the strongest mortality reduction evidence 6

Black Patients

• Preferred monotherapy: Calcium channel blockers OR thiazide diuretics (more effective than ACE inhibitors/ARBs as monotherapy) 1, 2
• Preferred combination therapy: CCB plus thiazide-like diuretic OR CCB plus ARB 1

Patients with Albuminuria or Chronic Kidney Disease

• Mandatory first-line choice: ACE inhibitor OR ARB, as these reduce albuminuria and slow CKD progression beyond BP lowering alone 1, 2

Patients with Coronary Artery Disease

• Preferred first-line: ACE inhibitor OR ARB 1, 2

Essential Lifestyle Modifications (For ALL Patients with BP >120/80 mmHg)

The following interventions have additive BP-lowering effects and enhance medication efficacy 5:

• Dietary sodium restriction: <2,300 mg/day 1, 2
• DASH diet pattern: Emphasized as potentially the most effective dietary intervention 4
• Increased potassium intake 1, 5
• Weight loss: If overweight or obese 1, 2
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly 1, 2, 7
• Alcohol restriction: Moderation or elimination 4, 5
• Smoking cessation 2

Blood Pressure Targets

• Adults <65 years: <130/80 mmHg 2
• Adults ≥65 years: Systolic <130 mmHg (individualize to <140/80 mmHg based on frailty) 1, 2

Critical Monitoring Requirements

• Follow-up timing: 7-14 days after medication initiation or dose changes 1, 2
• Goal achievement: Reach BP target within 3 months 1, 2
• Laboratory monitoring: Check serum creatinine and potassium when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1, 2

Important Contraindications and Caveats

• Never combine ACE inhibitors with ARBs (or add renin inhibitors to either): This increases adverse effects without additional benefit and is potentially harmful 3, 2
• Pregnancy: ACE inhibitors and ARBs are contraindicated; avoid in individuals of childbearing potential not using reliable contraception 2
• Single-pill combinations may improve adherence when multiple medications are needed 1

Common Pitfall to Avoid

The most frequent error is delaying pharmacological therapy in high-risk stage 1 hypertensive patients. Do not wait 3-6 months to start medication if the patient has ≥10% 10-year ASCVD risk, diabetes, CKD, or established CVD—these patients require immediate combination therapy with lifestyle modifications and antihypertensive medication 3, 2.