What is the initial management approach for a patient with hypertension?

Initial Management of Hypertension

For newly diagnosed hypertension, initiate both lifestyle modifications AND pharmacological therapy simultaneously with a two-drug combination (ACE inhibitor or ARB plus either a calcium channel blocker or thiazide diuretic, preferably as a single-pill combination) for patients with blood pressure ≥140/90 mmHg. 1

Confirming the Diagnosis

Before starting treatment, confirm hypertension using out-of-office measurements to exclude white coat hypertension 1:

• Home blood pressure monitoring: ≥135/85 mmHg confirms hypertension 1
• 24-hour ambulatory monitoring: ≥130/80 mmHg confirms hypertension 1
• Measure blood pressure in both arms using a validated automated upper arm cuff with appropriate cuff size 2

Initial Pharmacological Therapy

For Blood Pressure ≥140/90 mmHg (Stage 2 Hypertension)

Start with two medications immediately rather than sequential monotherapy, as this achieves blood pressure control faster and reduces cardiovascular risk more rapidly 1, 2:

Preferred two-drug combinations:

• ACE inhibitor (lisinopril 10 mg daily) + calcium channel blocker (amlodipine 5 mg daily) 1, 3
• ACE inhibitor (lisinopril 10 mg daily) + thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) 1, 4
• ARB (losartan 50 mg daily) + calcium channel blocker (amlodipine 5 mg daily) 1, 5

Use single-pill combinations whenever possible to improve medication adherence 1, 2

For Blood Pressure 130-139/80-89 mmHg (Stage 1 Hypertension)

Begin with a single antihypertensive agent if target organ damage, established cardiovascular disease, diabetes, or 10-year cardiovascular disease risk ≥20% is present 6, 1:

• ACE inhibitor (lisinopril 10 mg daily) as first-line for non-Black patients 1, 3
• ARB (losartan 50 mg daily) as alternative 1, 5

Special Population Considerations

For Black patients, initial therapy should include 1:

• ARB + calcium channel blocker, OR
• Calcium channel blocker + thiazide diuretic
• (ACE inhibitors have reduced efficacy as monotherapy in this population)

Absolute contraindications 1:

• ACE inhibitors, ARBs, and direct renin inhibitors are contraindicated in pregnancy or women planning pregnancy due to fetal injury and death

Lifestyle Modifications (Initiate Simultaneously with Medications)

Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with BP ≥140/90 mmHg 1, 2. However, lifestyle changes should be implemented alongside medications as they enhance drug efficacy 6, 7:

Dietary Interventions

• DASH diet pattern: 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products (can lower systolic BP by 5-8 mmHg) 1, 2
• Sodium restriction: <2,300 mg/day 1, 2
• Potassium supplementation: Through fruits and vegetables 1
• Eliminate table salt use 6

Weight and Physical Activity

• Weight reduction: Target BMI 20-25 kg/m² (expect ~1 mmHg systolic BP reduction per kg lost) 1, 2
• Regular aerobic exercise: At least 150 minutes of moderate-intensity activity per week 1

Alcohol and Smoking

• Moderate alcohol intake: ≤2 drinks/day for men, ≤1 drink/day for women 1
• Smoking cessation: Recommended for all patients 1

Blood Pressure Targets

Target blood pressure goals 1:

• Adults <65 years: <130/80 mmHg
• Adults ≥65 years: Systolic <130 mmHg
• Patients with diabetes, chronic kidney disease, or established cardiovascular disease: <130/80 mmHg 6

Achieve target within 3 months of treatment initiation 1, 2

Titration Strategy

If BP Not Controlled on Two Drugs

Escalate to three-drug combination: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 1, 2

If BP Not Controlled on Three Drugs (Resistant Hypertension)

Add spironolactone 25-50 mg daily as fourth agent 1, 2:

• Monitor serum potassium and creatinine 2-4 weeks after initiation, especially with concurrent RAS blocker use 2

Follow-Up and Monitoring

• Recheck blood pressure in 1 month after initiating or adjusting therapy 1, 2
• Follow-up every 1-3 months until BP is controlled 1
• Monitor serum creatinine and potassium 7-14 days after starting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Monitor for hypokalemia when using diuretics 1

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB) as this is potentially harmful 2
• Do not use monotherapy for stage 2 hypertension (≥160/100 mmHg): these patients require dual therapy from the start 2
• Avoid delaying pharmacotherapy for lifestyle modification trial in patients with BP ≥140/90 mmHg 1
• Prefer chlorthalidone over hydrochlorothiazide due to longer half-life and superior cardiovascular outcome data 1, 4
• Avoid beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease) 1
• Measure standing blood pressure in elderly patients and those with diabetes to assess for orthostatic hypotension 6