Initial Treatment for Hypertension
For newly diagnosed hypertension, begin lifestyle modifications immediately and initiate pharmacologic therapy with a single first-line agent (ACE inhibitor, ARB, thiazide-like diuretic, or dihydropyridine calcium channel blocker) if blood pressure is 130-150/80-90 mmHg, or start with two agents simultaneously if blood pressure is ≥150/90 mmHg. 1
Confirming the Diagnosis
Before initiating treatment, confirm hypertension using out-of-office measurements rather than relying solely on office readings 1:
Lifestyle Modifications (Foundation of All Treatment)
Implement these changes immediately for all patients with elevated blood pressure 1, 2:
- Dietary pattern: Follow DASH or Mediterranean diet with 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products, and reduced saturated/trans fats 1
- Sodium restriction: Limit to <2,300 mg/day, ideally <1,500 mg/day 1
- Potassium intake: Increase through dietary sources 1
- Weight management: Achieve caloric restriction if BMI ≥25 kg/m² 1
- Physical activity: At least 150 minutes of moderate-intensity aerobic exercise per week 1
- Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women 1
- Smoking cessation: For all patients 1
When to Initiate Pharmacologic Therapy
Start medication immediately (do not wait for lifestyle modification trial) if: 1
- Established cardiovascular disease
- Chronic kidney disease
- Diabetes mellitus
- Target organ damage
- 10-year ASCVD risk ≥10%
For lower-risk patients with blood pressure 130-150/80-90 mmHg: Start with lifestyle modifications, but add pharmacotherapy if blood pressure remains elevated after 3-6 months 3, 1
First-Line Pharmacologic Agents
Choose from four equally effective classes 1:
- ACE inhibitors (e.g., lisinopril 10 mg daily) 4
- ARBs (e.g., losartan 50 mg daily) 5
- Thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide) 1
- Dihydropyridine calcium channel blockers (e.g., amlodipine) 1
Monotherapy vs. Combination Therapy
For blood pressure 130-150/80-90 mmHg: Start with a single agent 1
For blood pressure ≥150/90 mmHg or ≥160/100 mmHg: Start with two agents simultaneously from different classes, preferably as a single-pill combination to improve adherence 1, 6
Special Population Considerations
Black patients: Initial therapy should include ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic (ACE inhibitors less effective as monotherapy) 3, 1
Diabetes mellitus: Use ACE inhibitor or ARB as first-line to reduce progressive kidney disease risk 1
Chronic kidney disease or albuminuria: ACE inhibitor or ARB should be included in initial regimen 1
Coronary artery disease: ACE inhibitor or ARB as first-line; add beta-blocker if history of myocardial infarction, active angina, or heart failure with reduced ejection fraction 1
Pregnancy or planning pregnancy: Avoid ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors (teratogenic) 6
Blood Pressure Targets
- Adults <65 years: <130/80 mmHg 1
- Adults ≥65 years: Systolic <130 mmHg if well-tolerated 1
- Patients with diabetes, CKD, or established CVD: <130/80 mmHg 1
Monitoring and Follow-Up
Initial follow-up: Recheck blood pressure in 1 month after initiating therapy 1
Laboratory monitoring: Check serum creatinine and potassium 7-14 days after starting or adjusting doses of ACE inhibitors, ARBs, or diuretics 1
Watch for:
Titration strategy: If starting with monotherapy, titrate to full dose of initial agent before adding a second drug 1
Common Pitfalls to Avoid
- Do not delay pharmacotherapy for lifestyle modification trial in high-risk patients or those with blood pressure ≥140/90 mmHg 6
- Avoid hydrochlorothiazide when chlorthalidone or indapamide are available (longer-acting thiazide-like diuretics preferred) 6
- Do not use beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease, post-MI) 6
- Confirm diagnosis with out-of-office measurements before committing patients to lifelong therapy 1