What is the recommended treatment for Hypertension (HTN)?

Treatment of Hypertension

Recommended Initial Treatment Strategy

For most patients with confirmed hypertension, start with combination therapy using two first-line antihypertensive agents, preferably as a single-pill combination, selecting from ACE inhibitors, ARBs, calcium channel blockers (CCBs), or thiazide/thiazide-like diuretics. 1

The preferred initial combinations are:

• A renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) + a dihydropyridine calcium channel blocker, OR
• A RAS blocker + a thiazide/thiazide-like diuretic 1, 2

Single-pill combinations are strongly recommended because they significantly improve medication adherence compared to separate pills. 1

Blood Pressure Targets

The target blood pressure varies by age and should guide treatment intensity:

• Adults <65 years: <130/80 mmHg 1
• Adults ≥65 years: Systolic 120-130 mmHg (if tolerated) 1, 3
• Patients with diabetes or CKD with proteinuria: <130/80 mmHg 4, 1
• Diastolic target: <80 mmHg but not <70 mmHg (excessive diastolic lowering may increase cardiovascular events) 3

Achieve target blood pressure within 3 months to maintain patient confidence and reduce cardiovascular risk. 3

Treatment Algorithm by Blood Pressure Level

For BP 140-159/90-99 mmHg (Grade 1 Hypertension):

• Step 1: Initiate two-drug combination at low doses (RAS blocker + CCB or diuretic) 1
• Monitor response after 4-6 weeks

For BP ≥160/100 mmHg (Severe Hypertension):

• Requires immediate combination therapy with two drugs or single-pill combination 3
• Do NOT use monotherapy at this blood pressure level—this is a critical pitfall that delays adequate control 3

If Target Not Achieved on Two Drugs:

• Step 3: Escalate to triple therapy: RAS blocker + CCB + thiazide/thiazide-like diuretic, preferably as single-pill combination 1, 3

Resistant Hypertension (Uncontrolled on Three Drugs):

• Add low-dose spironolactone (25-50 mg daily) 1, 3
• Reinforce lifestyle modifications 1
• Consider referral to hypertension specialist to exclude secondary causes 1

Special Population Considerations

Black Patients:

• Initial treatment should include a diuretic or CCB, either alone or in combination with a RAS blocker 1, 5
• RAS blockers have smaller blood pressure effects as monotherapy in Black patients 6, 7

Patients with Diabetes:

• Include a RAS blocker in the regimen 1
• Target BP <130/80 mmHg 4, 1

Patients with CKD and Proteinuria:

• A RAS blocker (ACE inhibitor or ARB) should be included to improve kidney outcomes 1, 5
• Target systolic BP 120-129 mmHg if eGFR >30 mL/min/1.73m² 1

Elderly Patients (≥65 years):

• Treatment may need more gradual initiation with consideration of frailty and comorbidities 1
• Target systolic BP 120-130 mmHg if tolerated 1

Essential Lifestyle Modifications

All patients should receive counseling on lifestyle changes, which enhance pharmacologic therapy effectiveness:

• Sodium restriction to <2,300 mg/day 3, 2
• Weight reduction if BMI >25 kg/m² (target BMI 20-25 kg/m²) 4, 3, 2
• Moderate-to-vigorous physical activity ≥150 minutes/week 3, 2
• Alcohol limitation to <100 g/week (preferably avoid) 4, 3, 2
• Smoking cessation 4, 3, 2
• DASH dietary pattern with high potassium intake 2

The blood pressure-lowering effects of these lifestyle components are partially additive and can reduce the need for multiple medications. 2

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB) — this increases adverse events including hyperkalemia, syncope, and acute kidney injury without additional cardiovascular benefit 1, 3
• Do not use monotherapy for BP ≥160/100 mmHg — this level requires immediate combination therapy 3
• Avoid excessive diastolic BP lowering (<60 mmHg) — may increase cardiovascular events in high-risk patients 3
• Do not delay treatment intensification when blood pressure remains uncontrolled on current regimen 1
• Always assess medication adherence before adding new medications or increasing doses 1

Improving Treatment Adherence

• Prescribe single-pill combinations whenever possible 1
• Use once-daily dosing regimens 1
• Implement home blood pressure monitoring to provide patient feedback 1
• Consider multidisciplinary approaches involving pharmacists and other healthcare team members 1

Evidence Quality Note

The recommendation for combination therapy as initial treatment represents a shift from older guidelines. The 2007 European Society of Cardiology guidelines emphasized achieving BP <140/90 mmHg but were less specific about initial combination therapy. 4 Current evidence from the European Society of Cardiology (2025) and JAMA reviews strongly support starting with combination therapy for most patients to achieve faster and more effective blood pressure control, which translates to reduced cardiovascular morbidity and mortality. 1, 2 A 10 mmHg reduction in systolic blood pressure decreases cardiovascular events by approximately 20-30%. 2