What is the recommended treatment for hypertension?

Recommended Treatment for Hypertension

For most adults with confirmed hypertension, initiate combination therapy immediately with two first-line agents—specifically a RAS blocker (ACE inhibitor or ARB) combined with either a calcium channel blocker or thiazide/thiazide-like diuretic—preferably as a single-pill combination, while simultaneously implementing lifestyle modifications. 1, 2

Treatment Thresholds and Risk Stratification

When to Start Pharmacological Treatment:

• Immediate drug therapy is indicated for sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg 3
• For BP 140-159/90-99 mmHg, initiate treatment based on presence of target organ damage, cardiovascular disease, diabetes, or 10-year coronary heart disease risk >15% 3
• Calculate cardiovascular disease risk to guide treatment intensity for borderline hypertension (130-139/80-89 mmHg) 2

First-Line Pharmacological Treatment Algorithm

Step 1: Initial Two-Drug Combination

• Start with a RAS blocker (ACE inhibitor like lisinopril 4 or ARB like losartan 5) PLUS either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic 1, 2
• Prescribe as a single-pill fixed-dose combination whenever possible to improve adherence 2
• For Black patients specifically, initial therapy should include a thiazide-like diuretic plus calcium channel blocker, or calcium channel blocker plus ARB 2

Step 2: Escalation to Triple Therapy (if BP uncontrolled after 4 weeks)

• Add the third agent: RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1, 2

Step 3: Resistant Hypertension

• Consider ambulatory blood pressure monitoring to exclude white coat hypertension 3
• Add additional agents as needed, but never combine two RAS blockers (ACE inhibitor + ARB) due to increased adverse effects without additional benefit 2

The most recent European Society of Cardiology guidelines 1, 2 represent a significant departure from older British Hypertension Society recommendations 3, which favored thiazide diuretics or β-blockers as monotherapy. Current evidence strongly supports starting with combination therapy rather than monotherapy to achieve target BP within 3 months 1.

Blood Pressure Targets

Standard Targets:

• Systolic BP 120-129 mmHg and diastolic BP <80 mmHg for adults <65 years if well tolerated 1, 2
• Systolic BP 130-139 mmHg for adults ≥65 years 2
• The older guideline minimum acceptable standard of <150/<90 mmHg 3 is now considered inadequate

Special Population Targets:

• Diabetes: <130/80 mmHg 1, 2
• Chronic kidney disease: 120-129 mmHg systolic if tolerated (for eGFR >30 mL/min/1.73m²) 1, 2
• Coronary artery disease: <130/80 mmHg 2
• Previous stroke/TIA: 120-130 mmHg systolic 2

Essential Lifestyle Modifications (For ALL Patients)

These should be implemented immediately and maintained even if medications are required 3, 6:

Weight Management:

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 2
• Weight reduction through caloric restriction is recommended for all overweight patients 1, 6

Dietary Modifications:

• Sodium restriction to <2,300 mg/day 1
• 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 1
• Elimination of sugar-sweetened beverages and restriction of free sugar to maximum 10% of energy intake 1

Physical Activity:

• Minimum 150 minutes/week of moderate-intensity aerobic activity or 75 minutes/week of vigorous activity, plus resistance training 2-3 times weekly 2
• Predominantly dynamic exercise (brisk walking) rather than isometric (weight training) 3

Alcohol Limitation:

• ≤2 drinks/day for men and ≤1 drink/day for women 1
• Maximum 14 units/week for men and 9 units/week for women 7

Tobacco Cessation:

• Complete cessation with referral to smoking cessation programs 1

The evidence for lifestyle modifications is robust, with randomized controlled trials demonstrating BP-lowering effects as large as those seen in drug studies when sustained over 3+ years 8. A 10 mmHg systolic BP reduction decreases cardiovascular disease events by approximately 20-30% 6.

Special Considerations for Compelling Indications

Albuminuria/Proteinuria:

• RAS blockers are first-line due to superior albuminuria reduction 1, 2

Heart Failure with Preserved Ejection Fraction (HFpEF):

• SGLT2 inhibitors are recommended for symptomatic patients 1

Heart Failure (general):

• Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists; consider ARNI as alternative to ACE inhibitor/ARB 2

Coronary Artery Disease:

• Use RAS blockers and beta-blockers as first-line agents 2

Critical Monitoring and Follow-Up

• Achieve target BP within 3 months 1
• Monitor renal function and potassium at least annually when using ACE inhibitor, ARB, or diuretic 1
• Regular BP monitoring using both office and home readings 2
• Annual cardiovascular risk reassessment 2
• Maintain treatment lifelong, even beyond age 85, if well tolerated 1, 2

Common Pitfalls to Avoid

• Do not start with monotherapy in most patients—current evidence favors immediate combination therapy 1, 2
• Do not combine two RAS blockers (ACE inhibitor + ARB)—this increases adverse effects without benefit 2
• Do not neglect lifestyle modifications even when starting medications—they enhance drug efficacy and may reduce medication requirements 3, 6
• Do not forget to measure standing BP in elderly or diabetic patients to exclude orthostatic hypotension 3
• Only 44% of US adults with hypertension achieve control to <140/90 mmHg 6, highlighting the importance of aggressive treatment and adherence strategies