What is the ideal treatment for a patient with stage 1 hypertension and blood pressure ranges of systolic 135-145 and diastolic 90-98?

Stage 1 Hypertension Management

For a patient with blood pressure 135-145/90-98 mmHg (Stage 1 Hypertension), initiate pharmacological treatment immediately with a thiazide-type diuretic as first-line therapy for most patients, or an ACE inhibitor/ARB for non-Black patients, targeting a blood pressure <130/80 mmHg. 1

Blood Pressure Classification

Your patient has Stage 1 Hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg). 1 This classification mandates specific treatment decisions based on the presence of cardiovascular risk factors or target organ damage.

Treatment Algorithm

Step 1: Immediate Pharmacological Therapy

Start antihypertensive medication immediately because this patient meets criteria for drug treatment (sustained BP ≥140/90 mmHg). 1 Do not delay with lifestyle modifications alone for 3-6 months—that approach is only appropriate for high-normal BP (120-139/80-89 mmHg). 1

Step 2: First-Line Medication Selection

For most patients (non-Black, no compelling indications):

• Thiazide-type diuretic (hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily) is the preferred initial agent 1, 2
• Alternative first-line options include ACE inhibitors, ARBs, or calcium channel blockers 1

For Black patients:

• Start with a calcium channel blocker (amlodipine 5-10 mg daily) or thiazide diuretic 3, 4
• Alternatively, use a combination of calcium channel blocker plus thiazide diuretic 3

Step 3: Blood Pressure Targets

• Primary target: <130/80 mmHg for most adults 3, 2
• Minimum acceptable target: <140/90 mmHg 1
• Achieve target within 3 months of initiating therapy 3

Step 4: Monitoring and Follow-Up

• Schedule follow-up within 2-4 weeks after starting medication 3
• Reassess BP, medication adherence, and side effects at each visit 3
• If target not achieved on monotherapy, add a second agent from a different class 1

Concurrent Lifestyle Modifications

While starting medication immediately, implement these lifestyle changes that provide additive BP reduction of 10-20 mmHg: 4

• Weight reduction if overweight (target BMI 20-25 kg/m²) 1
• Sodium restriction to <2.34 g/day 1, 4
• DASH diet (rich in fruits, vegetables, low-fat dairy; reduced saturated fat) 1, 5
• Physical activity 30-45 minutes daily 1
• Alcohol limitation (if consumed) 1
• Smoking cessation 1

Critical Pitfalls to Avoid

Do not delay pharmacological treatment waiting for lifestyle modifications alone—Stage 1 hypertension with these BP levels requires immediate drug therapy. 1 The 3-6 month lifestyle trial is only for high-normal BP (prehypertension), not established Stage 1 hypertension. 1

Do not use immediate-release nifedipine for BP control—it should be avoided due to unpredictable effects. 6

Do not undertreate—only 44% of US adults with hypertension achieve adequate control, contributing to preventable cardiovascular morbidity and mortality. 2 Antihypertensive therapy reduces stroke risk by 35-44% and overall cardiovascular events by 20-30% per 10 mmHg systolic reduction. 1, 2

When to Escalate Therapy

If BP remains uncontrolled after 2-4 weeks on optimized monotherapy:

• Add a second agent from a complementary class (e.g., if started on thiazide, add ACE inhibitor or calcium channel blocker) 3, 4
• For non-Black patients: typical sequence is ACE inhibitor/ARB → add calcium channel blocker → add thiazide diuretic 3, 4
• Refer to hypertension specialist if BP remains uncontrolled on three or more medications 3