What is the recommended initial treatment for hypertension?

Initial Treatment for Hypertension

For most adults with newly diagnosed hypertension, begin with lifestyle modifications immediately, and initiate pharmacologic therapy with a single first-line agent (ACE inhibitor, ARB, thiazide-like diuretic, or dihydropyridine calcium channel blocker) if blood pressure is 130-150/80-90 mmHg, or start with two agents simultaneously if blood pressure is ≥150/90 mmHg or ≥160/100 mmHg. 1, 2

Confirming the Diagnosis

• Confirm hypertension using out-of-office measurements before initiating treatment—either home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg)—rather than relying solely on office readings 1

Lifestyle Modifications (Foundation for All Patients)

Implement these interventions in all patients with blood pressure >120/80 mmHg, regardless of whether pharmacologic therapy is started:

• Dietary changes: Follow a DASH (Dietary Approaches to Stop Hypertension) or Mediterranean eating pattern emphasizing 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products, and reduced saturated/trans fats 1, 3, 4
• Sodium restriction: Limit intake to <2,300 mg/day (ideally <1,500 mg/day) 1, 3
• Potassium supplementation: Increase intake through dietary sources 1, 3
• Weight loss: Achieve caloric restriction if overweight (BMI ≥25 kg/m²) 1, 4
• Physical activity: Engage in at least 150 minutes of moderate-intensity aerobic exercise per week 1, 3
• Alcohol moderation: Limit to ≤2 drinks/day for men, ≤1 drink/day for women 1, 3
• Smoking cessation: Recommend for all patients 1, 3

Pharmacologic Therapy: When to Start

Blood Pressure 130-150/80-90 mmHg

• Start with a single antihypertensive agent from first-line options 1, 2
• Initiate pharmacotherapy immediately (do not delay for 3-6 months of lifestyle modification alone) if the patient has high cardiovascular risk: established CVD, chronic kidney disease, diabetes, target organ damage, or 10-year ASCVD risk ≥10% 1, 3, 2

Blood Pressure ≥150/90 mmHg or ≥160/100 mmHg

• Start with two antihypertensive agents simultaneously from different classes, preferably as a single-pill combination to improve adherence 5, 1, 2
• This approach achieves blood pressure control faster and reduces cardiovascular risk more rapidly than sequential monotherapy 1

First-Line Pharmacologic Agents

Choose from these four classes, all equally effective at reducing cardiovascular events:

• ACE inhibitors (e.g., lisinopril 10 mg daily, titrate to 20-40 mg daily) 1, 6, 4
• Angiotensin receptor blockers (ARBs) (e.g., losartan 50 mg daily, titrate to 100 mg daily) 1, 7, 4
• Thiazide-like diuretics (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 1, 4
• Dihydropyridine calcium channel blockers (e.g., amlodipine 5 mg daily) 1, 4

Recommended Two-Drug Combinations for Blood Pressure ≥150/90 mmHg

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker (preferred combination) 1, 2
• RAS blocker (ACE inhibitor or ARB) + thiazide-like diuretic (alternative combination) 1, 2
• Single-pill combinations are strongly preferred to improve adherence 5, 1

Special Population Considerations

Black Patients

• Initial therapy should include ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic due to reduced response to ACE inhibitors as monotherapy 1, 3

Patients with Diabetes

• Use ACE inhibitor or ARB as first-line therapy to reduce risk of progressive kidney disease 5, 2
• For blood pressure 140-159/90-99 mmHg, start with a single agent 5
• For blood pressure ≥160/100 mmHg, start with two agents 5

Patients with Chronic Kidney Disease or Albuminuria (UACR ≥30 mg/g)

• Initial treatment should include ACE inhibitor or ARB to reduce risk of progressive kidney disease 1, 3

Patients with Coronary Artery Disease

• Use ACE inhibitor or ARB as first-line therapy 1, 2
• Add beta-blocker if history of myocardial infarction, active angina, or heart failure with reduced ejection fraction 5, 2

Pregnant Women or Those Planning Pregnancy

• Absolutely contraindicated: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors due to fetal injury and death 1, 2
• Use calcium channel blockers or methyldopa instead 1

Pediatric Patients (≥6 years)

• Start with ACE inhibitor (lisinopril 0.07 mg/kg once daily, up to 5 mg total) or ARB 5, 6
• Not recommended in children <6 years or with GFR <30 mL/min/1.73m² 5, 6

Blood Pressure Targets

• Most adults <65 years: <130/80 mmHg 1, 2, 4
• Adults ≥65 years: Systolic <130 mmHg if well-tolerated 1, 2, 4
• Patients with diabetes, CKD, or established CVD: <130/80 mmHg 2
• Pediatric patients: <90th percentile for age, sex, and height, or <120/80 mmHg in adolescents ≥13 years 5

Monitoring and Follow-Up

• Recheck blood pressure in 1 month after initiating therapy 1
• Monitor serum creatinine and potassium 7-14 days after starting or adjusting doses of ACE inhibitors, ARBs, or diuretics 1, 3, 2
• Watch for hyperkalemia with ACE inhibitors/ARBs and hypokalemia with diuretics 5, 2
• Titrate to full dose of initial agent before adding a second drug if starting with monotherapy 1
• If blood pressure remains uncontrolled on two drugs, escalate to a three-drug combination (RAS blocker + calcium channel blocker + thiazide-like diuretic) 1
• Achieve blood pressure control within 3 months, with follow-up every 1-3 months until controlled 1

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with blood pressure ≥140/90 mmHg and high cardiovascular risk 1
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics have superior outcomes 1
• Do not use beta-blockers as initial therapy unless specific indications exist (prior MI, angina, heart failure with reduced ejection fraction) 5, 1
• Do not use ACE inhibitors/ARBs in patients with severe bilateral renal artery stenosis due to acute renal failure risk 1
• Avoid thiazides in patients with active gout unless on uric acid-lowering therapy 1