What is the initial management of hypertension?

Initial Management of Hypertension

For most adults with confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications AND pharmacological therapy simultaneously with a two-drug combination, preferably as a single-pill combination. 1

Confirming the Diagnosis

• Confirm hypertension using out-of-office measurements before starting treatment: home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg). 1, 2
• Measure BP in both arms at the first visit and use the arm with higher readings for subsequent measurements. 2

Lifestyle Modifications (Start Immediately)

All patients with BP >120/80 mmHg should implement comprehensive lifestyle changes alongside medications, as they enhance drug efficacy. 1, 3

Dietary Interventions

• Adopt the DASH (Dietary Approaches to Stop Hypertension) eating pattern, which may be the most effective lifestyle intervention for BP reduction. 1, 4
• Consume 8-10 servings/day of fruits and vegetables for increased potassium intake. 1
• Include 2-3 servings/day of low-fat dairy products. 1
• Restrict sodium to <2,300 mg/day (eliminate table salt use). 1

Other Essential Modifications

• Achieve weight loss if overweight through caloric restriction. 1
• Engage in at least 150 minutes of moderate-intensity aerobic activity per week. 1
• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women. 1
• Complete smoking cessation. 1

Initial Pharmacological Therapy

Standard Approach (BP ≥140/90 mmHg)

Start with a two-drug combination from different classes, preferably as a single-pill combination to improve adherence. 1, 2

First-Line Combination Options:

Option 1 (Preferred): RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker 1, 2

• Example: Lisinopril 10 mg + amlodipine 5 mg daily 1, 5

Option 2: RAS blocker (ACE inhibitor or ARB) + thiazide-like diuretic 1, 2

• Example: Lisinopril 10 mg + chlorthalidone 12.5-25 mg daily 1
• Note: Chlorthalidone is preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcome data. 1

Special Population Considerations:

• Black patients: Start with ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic (due to reduced response to ACE inhibitors as monotherapy). 1, 2
• Patients with coronary artery disease: Include ACE inhibitor or ARB as first-line therapy. 1
• Patients with albuminuria (UACR ≥30 mg/g): Must include ACE inhibitor or ARB to reduce progressive kidney disease risk. 1
• Patients with heart failure: Add beta-blockers in addition to other agents. 1

Lower-Grade Hypertension (BP 130-150/80-90 mmHg)

• For BP between 130/80 and 150/90 mmHg, begin with a single antihypertensive agent. 1
• Lisinopril 10 mg daily is an appropriate starting dose for initial monotherapy. 1, 5
• Do not delay pharmacologic treatment for 3-6 months of lifestyle modification alone in patients with BP ≥140/90 mmHg, as current evidence favors earlier intervention. 1

Blood Pressure Targets

• Target BP <130/80 mmHg for most adults under 65 years. 1, 2
• Target systolic BP 120-129 mmHg for adults 65-85 years if well tolerated. 1, 2
• For patients with diabetes, chronic kidney disease, or established cardiovascular disease: target <130/80 mmHg. 1

Monitoring and Follow-Up

• Recheck BP within 1 month after initiating therapy. 1
• Achieve BP control within 3 months, with follow-up every 1-3 months until controlled. 1, 2
• Check serum creatinine and potassium 7-14 days after initiation or dose changes of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 1, 2
• Monitor for hypokalemia when using diuretics. 1

Titration Strategy if BP Not Controlled

1. Increase ACE inhibitor/ARB to full dose before adding additional agents (e.g., lisinopril from 10 mg to 20-40 mg daily). 1, 5
2. If still uncontrolled, escalate to three-drug combination: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic. 1
3. If resistant to three drugs: Add low-dose spironolactone 25 mg daily. 1, 2
4. Beta-blockers and alpha-blockers are fourth- or fifth-line agents used when spironolactone is contraindicated or not tolerated. 1

Critical Contraindications to Avoid

• Absolutely contraindicated in pregnancy or women planning pregnancy: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors (due to fetal injury and death). 1, 2
• Avoid ACE inhibitors in patients with history of angioedema. 1
• Avoid ACE inhibitors/ARBs in severe bilateral renal artery stenosis (acute renal failure risk). 1
• Use thiazides cautiously in patients with gout unless on uric acid-lowering therapy. 1

Common Pitfalls

• Do not use beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease). 1
• Do not use hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics are preferred. 1
• Do not delay pharmacotherapy for lifestyle modification trial in patients with BP ≥140/90 mmHg. 1
• Do not start with monotherapy in Stage 2 hypertension (BP >20/10 mmHg above target), as two-drug combination achieves control faster and reduces cardiovascular risk more rapidly. 1