When is initiating anti-hypertensive (blood pressure lowering) medication recommended?

When to Initiate Antihypertensive Medication

Initiate antihypertensive drug therapy immediately for Stage 2 hypertension (BP ≥140/90 mmHg) regardless of cardiovascular risk, and for Stage 1 hypertension (BP 130-139/80-89 mmHg) when 10-year atherosclerotic cardiovascular disease (ASCVD) risk is ≥10%, established cardiovascular disease is present, or high-risk conditions exist (diabetes with albuminuria, chronic kidney disease, or hypertension-mediated organ damage). 1

Blood Pressure Thresholds for Drug Initiation

Stage 2 Hypertension (BP ≥140/90 mmHg)

• Start medication promptly at diagnosis, within a few weeks or simultaneously with lifestyle modifications 1
• This applies to all patients regardless of cardiovascular risk level 1
• For BP ≥150/90 mmHg in patients with diabetes, initiate with two antihypertensive medications to achieve control more rapidly 1
• For BP >20/10 mmHg above target (typically Stage 2), begin with combination therapy using two first-line agents 1

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

Initiate medication immediately if:

• 10-year ASCVD risk ≥10% 1
• Established cardiovascular disease (prior MI, stroke, heart failure, peripheral arterial disease) 1
• Diabetes with albuminuria (UACR ≥30 mg/g) 1
• Chronic kidney disease (eGFR <60 mL/min/1.73 m²) 1
• Hypertension-mediated organ damage (left ventricular hypertrophy, retinopathy, microalbuminuria) 1

Consider medication after 3-6 months of lifestyle intervention if:

• 10-year ASCVD risk 5-10% with risk modifiers present 1
• BP remains elevated despite adherence to lifestyle modifications 1
• Low-to-moderate cardiovascular risk but BP persistently ≥130/80 mmHg on multiple visits 1

Elevated BP (120-129/70-79 mmHg)

• Lifestyle modifications only for most patients 1
• Drug therapy may be considered after 3 months if high cardiovascular risk (≥10% 10-year ASCVD risk) and lifestyle changes fail 1
• Do not initiate medication in low-risk patients with elevated BP 1

Special Populations

Elderly Patients (≥65 years)

• Initiate medication when SBP ≥140 mmHg 1
• For age ≥80 years, initiate when SBP ≥160 mmHg 1
• Use clinical judgment in frail elderly, those with orthostatic hypotension, or limited life expectancy (<3 years) 1
• Start with low doses and titrate slowly to avoid hypotension 1

Diabetes

• Initiate medication at BP 130-139/80-89 mmHg 1
• Start with two drugs if BP ≥150/90 mmHg 1
• ACE inhibitor or ARB required if albuminuria present (UACR ≥30 mg/g) 1

Chronic Kidney Disease

• Initiate medication at BP ≥130/80 mmHg 1
• ACE inhibitor or ARB preferred as first-line therapy 1

Initial Medication Strategy

Monotherapy vs. Combination Therapy

Start with two medications when:

• Stage 2 hypertension with BP >20/10 mmHg above target 1
• BP ≥150/90 mmHg in patients with diabetes 1
• Fixed-dose combinations improve adherence and achieve faster BP control 1

Start with single medication when:

• Stage 1 hypertension (BP 130-139/80-89 mmHg) with target <130/80 mmHg 1
• Elderly patients or those at risk for hypotension 1
• History of medication-related side effects 1

First-Line Drug Classes

Choose from these four classes based on comorbidities 1, 2:

• Thiazide or thiazide-like diuretics (chlorthalidone, hydrochlorothiazide) 1, 3
• ACE inhibitors (enalapril, lisinopril) - preferred for diabetes with albuminuria, CKD, heart failure, post-MI 1
• Angiotensin receptor blockers (ARBs) - alternative to ACE inhibitors 1
• Dihydropyridine calcium channel blockers (amlodipine) 1, 2

Common Pitfalls to Avoid

Therapeutic inertia: Do not delay medication initiation beyond recommended timeframes. For Stage 2 hypertension or high-risk Stage 1 hypertension, waiting months for lifestyle changes alone increases cardiovascular risk 1

Undertreating high-risk patients: Patients with diabetes, CKD, or established CVD require medication at lower BP thresholds (≥130/80 mmHg) than the general population 1

Overly aggressive treatment in vulnerable populations: Avoid initiating medication in patients ≥85 years, those with severe frailty, symptomatic orthostatic hypotension, or limited life expectancy until BP >140/90 mmHg 1

Ignoring out-of-office BP measurements: Confirm hypertension diagnosis with home BP monitoring or 24-hour ambulatory BP monitoring before initiating treatment, especially in Stage 1 hypertension 1

Follow-Up After Initiation

• Monthly visits for medication titration until BP control achieved 1
• Target BP control within 3 months of starting therapy 1
• Monitor for adverse effects: serum creatinine and potassium 7-14 days after starting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1