What are the initial treatment guidelines for antihypertensive (high blood pressure) therapy?

Antihypertensive Starting Guidelines

For most adults with uncomplicated hypertension, initiate treatment with a thiazide-type diuretic (chlorthalidone or hydrochlorothiazide) as first-line monotherapy, or immediately start combination therapy with two first-line agents if blood pressure is ≥20/10 mm Hg above target or stage 2 hypertension (≥140/90 mm Hg). 1

Blood Pressure Thresholds for Starting Medication

• Start pharmacotherapy immediately when confirmed BP is ≥140/90 mm Hg in all adults 1
• Consider starting at 130-139/80-89 mm Hg in high-risk patients with existing cardiovascular disease, diabetes, chronic kidney disease, or 10-year ASCVD risk ≥10% 2, 1
• Lifestyle modifications alone are appropriate for BP 120-129/<80 mm Hg 2

First-Line Medication Selection Algorithm

For Uncomplicated Hypertension (No Comorbidities)

Preferred initial agent: Thiazide-type diuretic 2, 1

• Chlorthalidone 12.5-25 mg daily (strongest evidence for mortality reduction) 3
• Hydrochlorothiazide 12.5-25 mg daily (if chlorthalidone unavailable) 2, 3
• These agents have the most robust evidence for reducing cardiovascular morbidity and mortality 4, 3

Alternative first-line options (if diuretic contraindicated or not tolerated):

• ACE inhibitor (lisinopril 10 mg daily) 1, 5
• ARB (losartan 50 mg daily) 1, 6
• Long-acting calcium channel blocker (amlodipine 5 mg daily) 1, 4

Population-Specific Modifications

Black patients without heart failure or CKD:

• Start with thiazide-type diuretic OR calcium channel blocker 2, 1
• These classes are more effective as monotherapy in this population 2
• ACE inhibitors/ARBs are less effective as monotherapy but can be added as second agents 2

Patients with diabetes and albuminuria:

• Start with ACE inhibitor or ARB as first-line 1
• Provides renal protection beyond BP lowering 1

Patients with chronic kidney disease:

• ACE inhibitor or ARB as first-line therapy 1

Patients with thoracic aortic disease:

• Beta-blocker as preferred first-line agent 2, 1

Patients with stable ischemic heart disease:

• Beta-blocker, ACE inhibitor, or ARB for compelling cardiac indications 2

Monotherapy vs. Combination Therapy Decision

Start with Monotherapy if:

• Stage 1 hypertension (140-159/90-99 mm Hg) 2
• BP is <20/10 mm Hg above target 2, 1

Start with Combination Therapy (Two Drugs) if:

• Stage 2 hypertension (≥160/100 mm Hg) 2, 1
• BP is ≥20/10 mm Hg above target 2
• BP ≥150/90 mm Hg 1

Preferred two-drug combinations:

• Thiazide diuretic + ACE inhibitor or ARB 2, 1
• Thiazide diuretic + calcium channel blocker 1
• ACE inhibitor or ARB + calcium channel blocker 1
• Use single-pill combinations when possible to improve adherence 1

Blood Pressure Targets

• <130/80 mm Hg for adults <65 years with confirmed hypertension and known CVD or 10-year ASCVD risk ≥10% 2, 1
• <130/80 mm Hg may be reasonable for adults without additional CVD risk markers 2
• Systolic <130 mm Hg for adults ≥65 years if tolerated 1
• <130/80 mm Hg for patients with diabetes or CKD 2

Dosing Strategy

Start low and titrate up:

• Begin at appropriate initial dose for the chosen agent 5, 6
• Lisinopril: Start 10 mg daily, usual range 20-40 mg daily 5
• Losartan: Start 50 mg daily, can increase to 100 mg daily 6
• Titrate to maximum tolerated dose before adding second agent 1

For patients on diuretics or with volume depletion:

• Start ACE inhibitors at lower dose (lisinopril 5 mg) 5
• Start ARBs at lower dose (losartan 25 mg) 6

Monitoring Schedule

• Monthly follow-up after initiation or dose changes until BP target achieved 2, 1
• Assess adherence and response to treatment at each visit 2
• Once controlled, follow-up every 3-5 months 7
• Home BP monitoring strongly recommended with target <135/85 mm Hg 1
• Monitor potassium and creatinine within 7-14 days when starting ACE inhibitors or ARBs 1

Critical Pitfalls to Avoid

Do not use beta-blockers as first-line therapy without specific cardiac indications (post-MI, heart failure, stable angina), as they are less effective for stroke prevention compared to other first-line agents 1

Do not undertreat by using inadequate doses:

• Titrate each medication to maximum tolerated dose before adding additional agents 1
• Most patients require two or more medications to achieve target BP 2

Do not ignore adherence barriers:

• Address cost, side effects, and complexity of regimen 1
• Use single-pill combinations when possible 1

Avoid excessive diastolic lowering:

• Use caution if diastolic BP drops below 60 mm Hg in patients with coronary artery disease, diabetes, or age >60 years 7

Do not start combination therapy in patients at risk for orthostatic hypotension without careful monitoring 2