What is the best initial antihypertensive (blood pressure medication) to start in a 50-year-old man with stage 1 hypertension and a body mass index (BMI) of 29?

Initial Antihypertensive Selection for Stage 1 Hypertension

For this 50-year-old man with BP 140/85-89 and BMI 29, begin with lifestyle modifications for 3-6 months before initiating pharmacotherapy, and if medication becomes necessary, start with any single agent from four equally effective first-line options: ACE inhibitor, ARB, thiazide-like diuretic, or dihydropyridine calcium channel blocker. 1

Blood Pressure Classification and Treatment Threshold

• This patient has stage 1 hypertension (BP 130-139/80-89 mmHg) without diabetes, chronic kidney disease, or established cardiovascular disease 1
• With BP between 130/80 and 150/90 mmHg, single-drug therapy is appropriate if pharmacologic treatment is initiated 1
• The 2025 American Diabetes Association guidelines specifically state that patients in this BP range "may begin with a single drug" 1

Lifestyle Modifications: The Critical First Step

Lifestyle intervention should be the initial approach for this patient, as his BP is only mildly elevated and he has no compelling indications for immediate drug therapy 1

The following interventions can collectively reduce BP by 10-20 mmHg and may eliminate the need for medication 1, 2:

• Weight loss: Target reduction of at least 1 kg, ideally achieving BMI <25 kg/m² from current BMI of 29 1
• Sodium restriction: Reduce intake to <2,300 mg/day (ideally <1,500 mg/day) 1
• DASH diet pattern: 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 1
• Potassium supplementation: Increase dietary potassium to 3,500-5,000 mg/day 1
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week 1
• Alcohol moderation: Limit to ≤2 drinks per day for men 1

When to Initiate Pharmacotherapy

Reassess BP every 3-6 months during lifestyle modification 1

Initiate medication if:

• BP remains ≥140/90 mmHg after 3-6 months of lifestyle intervention 1
• BP rises to ≥150/90 mmHg at any point (requiring two-drug therapy) 1
• Patient develops diabetes, chronic kidney disease, or cardiovascular disease (lowering threshold to 130/80 mmHg) 1

First-Line Medication Options (All Equally Effective)

Any of these four drug classes can be selected as initial monotherapy, as all have demonstrated equivalent cardiovascular event reduction 1, 2, 3:

Option 1: ACE Inhibitor

• Example: Lisinopril 10 mg once daily or enalapril 5 mg once daily 2
• Advantages: Proven CV benefit, renoprotective if albuminuria develops 1
• Monitoring: Check serum creatinine and potassium 7-14 days after initiation 1
• Caution: Avoid in men planning conception with partners of childbearing potential 1

Option 2: Angiotensin Receptor Blocker (ARB)

• Example: Losartan 50 mg once daily (can increase to 100 mg) 4
• Advantages: Similar benefits to ACE inhibitors without cough side effect 1, 2
• Monitoring: Check serum creatinine and potassium 7-14 days after initiation 1
• Caution: Same reproductive precautions as ACE inhibitors 1

Option 3: Thiazide-Like Diuretic

• Example: Chlorthalidone 12.5-25 mg once daily (preferred over hydrochlorothiazide due to longer duration of action) 1, 5, 6
• Advantages: Particularly effective in volume-dependent hypertension, low cost 2, 6
• Monitoring: Check potassium at routine visits and 7-14 days after initiation for hypokalemia 1
• Additional benefit: May assist with weight loss efforts 1

Option 4: Dihydropyridine Calcium Channel Blocker

• Example: Amlodipine 5 mg once daily (can increase to 10 mg) 1, 2
• Advantages: No metabolic effects, effective across all patient populations 1, 3
• Side effect: Monitor for peripheral edema 7

Practical Selection Algorithm

Since this patient has no compelling indications (no diabetes, no albuminuria, no coronary artery disease, no chronic kidney disease), choose based on these practical considerations 1, 8:

1. If cost is a primary concern: Start with chlorthalidone 12.5 mg daily 6
2. If patient is concerned about metabolic effects: Start with amlodipine 5 mg daily 3
3. If planning for future CV protection: Start with lisinopril 10 mg or losartan 50 mg daily 1, 2
4. If patient has history of cough with ACE inhibitors: Choose ARB over ACE inhibitor 2

Target Blood Pressure and Follow-Up

• Target BP: <130/80 mmHg for this 50-year-old patient 1, 2
• Follow-up timing: Reassess approximately monthly during medication titration until BP is controlled 1
• Home BP monitoring: Encourage home measurements to confirm office readings (target <135/85 mmHg at home) 1
• Titration strategy: If BP not at goal after 2-4 weeks, increase to maximum dose of initial agent before adding second drug 1, 5

Critical Pitfalls to Avoid

• Do not delay lifestyle modifications even if medication is started—the effects are additive and may allow dose reduction 1, 2
• Do not start with beta-blockers or alpha-blockers as first-line therapy unless compelling indication exists (e.g., coronary disease, heart failure) 1, 2
• Do not combine ACE inhibitor with ARB—this increases adverse events without additional benefit 1, 5
• Do not assume treatment failure without first confirming medication adherence and ruling out white coat hypertension with home BP monitoring 1, 5

When to Add a Second Agent

If BP remains ≥140/90 mmHg after maximizing the first agent, add a second drug from a different class using this sequence 1, 5:

• If started with ACE inhibitor/ARB → add calcium channel blocker or thiazide diuretic 1
• If started with calcium channel blocker → add ACE inhibitor/ARB or thiazide diuretic 1
• If started with thiazide diuretic → add ACE inhibitor/ARB or calcium channel blocker 1

The goal is to achieve target BP within 3 months of initiating or modifying therapy 5, 2