What antihypertensive (blood pressure medication) would you prescribe for this patient?

Antihypertensive Selection for Initial Therapy

For most adults with hypertension, initiate treatment with a thiazide-like diuretic (chlorthalidone or indapamide), ACE inhibitor (ACEI), angiotensin receptor blocker (ARB), or calcium channel blocker (CCB), with selection based on patient age, race, and comorbidities. 1, 2

Age-Based Selection Algorithm

Patients <55 Years Old

• Start with an ACEI (such as lisinopril 10 mg daily) or ARB (such as losartan 50 mg daily) as first-line therapy 1
• These agents provide superior cardiovascular protection in younger patients with higher renin activity 1

Patients ≥55 Years Old or Black Patients (Any Age)

• Start with a CCB (such as amlodipine 5-10 mg daily) or thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) 1
• Black patients and older adults typically have lower renin activity, making CCBs and diuretics more effective 1
• Thiazide-like diuretics (chlorthalidone, indapamide) are preferred over hydrochlorothiazide due to superior cardiovascular outcomes 1, 2

Comorbidity-Specific Recommendations

Diabetes Mellitus

• Initiate with an ACEI or ARB regardless of age 1
• For blood pressure 130-160/80-100 mmHg: start with single agent 1
• For blood pressure ≥160/100 mmHg: start with two agents simultaneously (ACEI or ARB + thiazide-like diuretic or CCB) 1
• If albuminuria present (UACR ≥30 mg/g): ACEI or ARB is mandatory as first-line 1

Coronary Artery Disease

• ACEI or ARB is recommended as first-line therapy 1
• These agents provide superior cardiovascular protection in established coronary disease 1

Migraine

• Beta-blockers (metoprolol 80-240 mg/day, propranolol, or timolol 20-30 mg/day) are preferred as they treat both hypertension and prevent migraine attacks 3
• Second-line options include ARBs (candesartan) or ACEIs in combination with CCBs 3
• Avoid alpha-blockers due to orthostatic hypotension risk 3

Heart Failure with Reduced Ejection Fraction

• Start with ACEI (lisinopril 5 mg daily) or ARB in combination with diuretics 4
• Beta-blockers are indicated but primarily for heart failure management rather than blood pressure control alone 1

Initial Dosing Strategy

Single Agent Approach

• Start at standard initial dose and titrate to maximum recommended dose before adding second agent 1
• Reassess blood pressure every 2-4 weeks until control achieved 1

Two-Drug Combination (For BP ≥160/100 mmHg)

• Initiate two agents simultaneously to achieve faster blood pressure control 1
• Preferred combinations: 1
  • Thiazide + ACEI or ARB
  • CCB + ACEI or ARB
  • CCB + thiazide
• Single-pill combinations may improve medication adherence 1

Medications to Avoid in Combination

Never combine ACEI + ARB as this increases risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 1

Never combine ACEI or ARB + direct renin inhibitor due to similar adverse effects without benefit 1

Renal Impairment Considerations

Creatinine Clearance >30 mL/min

• No dose adjustment needed for most agents 4

Creatinine Clearance 10-30 mL/min

• Reduce initial ACEI dose by 50% (e.g., lisinopril 5 mg for hypertension, 2.5 mg for heart failure) 4
• Titrate cautiously to maximum 40 mg daily 4

Creatinine Clearance <10 mL/min or Hemodialysis

• Start lisinopril at 2.5 mg once daily 4

Target Blood Pressure Goals

• Adults <65 years: <130/80 mmHg 1, 2
• Adults ≥65 years: SBP <130 mmHg 1, 2
• Diabetes: <130/80 mmHg 1

Common Pitfalls to Avoid

• Do not use beta-blockers as first-line unless specific indication (migraine, coronary disease, heart failure) exists, as they have not shown mortality benefit for hypertension alone 1
• Avoid hydrochlorothiazide when thiazide-like diuretics (chlorthalidone, indapamide) are available, as the latter have superior cardiovascular outcomes 1, 2
• Monitor electrolytes when using diuretics to avoid hypokalemia and potential headache triggers 3
• Bedtime dosing is not superior to morning dosing and should not be preferentially recommended 1

Escalation for Uncontrolled Blood Pressure

On Single Agent

• Add thiazide-like diuretic if not already prescribed 5
• Maintain current medication while adding complementary class 5

On Two Agents

• Add third agent from different class (typically thiazide + CCB + ACEI or ARB) 1, 5

Resistant Hypertension (Uncontrolled on Three Agents Including Diuretic)

• Add spironolactone 25 mg daily 1, 5
• Verify medication adherence and exclude white coat hypertension before diagnosing resistant hypertension 1
• Consider referral to hypertension specialist if blood pressure remains uncontrolled 5