What are the initial treatment options for hypertension?

Initial Treatment for Hypertension

For adults with confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications and pharmacologic therapy simultaneously—starting with a single first-line agent (ACE inhibitor, ARB, thiazide-like diuretic, or calcium channel blocker) for BP 140-159/90-99 mmHg, or two agents from different classes for BP ≥160/100 mmHg. 1, 2

Confirming the Diagnosis

Before initiating treatment, confirm hypertension using out-of-office measurements rather than relying solely on office readings 1, 3:

• Home blood pressure monitoring: ≥135/85 mmHg indicates hypertension 1
• 24-hour ambulatory monitoring: ≥130/80 mmHg confirms the diagnosis 1, 2

Lifestyle Modifications (Initiate Immediately)

Lifestyle interventions should begin at BP >120/80 mmHg and continue alongside pharmacotherapy 2, 1:

Dietary changes:

• Follow a DASH eating pattern with 8-10 servings/day of fruits and vegetables 2, 1
• Consume 2-3 servings/day of low-fat dairy products 2, 1
• Restrict sodium to <2,300 mg/day (ideally <1,500 mg/day) 1, 3
• Increase potassium intake through dietary sources 2, 1

Weight and exercise:

• Achieve caloric restriction if BMI ≥25 kg/m² 1
• Engage in at least 150 minutes of moderate-intensity aerobic exercise per week 1

Substance use:

• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women 2, 1
• Complete smoking cessation 1, 3

Pharmacologic Therapy Algorithm

For BP 140-159/90-99 mmHg (Grade 1 Hypertension)

Start with monotherapy using one first-line agent 1, 2:

Non-Black patients:

• ACE inhibitor (e.g., lisinopril 10 mg daily) OR 1, 4
• ARB (e.g., losartan 50 mg daily) OR 1, 5
• Thiazide-like diuretic (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide) OR 1, 3
• Dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily) 1, 2

Black patients:

• ARB + dihydropyridine calcium channel blocker OR 2, 1
• Calcium channel blocker + thiazide-like diuretic 2, 3
• Rationale: Black patients show reduced response to ACE inhibitors as monotherapy 2, 1

For BP ≥160/100 mmHg (Grade 2 Hypertension)

Initiate two antihypertensive agents simultaneously from different classes, preferably as a single-pill combination 2, 1:

Recommended two-drug combinations:

• ACE inhibitor or ARB + thiazide-like diuretic 1, 3
• ACE inhibitor or ARB + dihydropyridine calcium channel blocker 1, 3
• Calcium channel blocker + thiazide-like diuretic 2, 3

Starting with two agents achieves BP control faster and improves adherence compared to sequential monotherapy 1, 3

Special Population Considerations

Diabetes mellitus:

• Use ACE inhibitor or ARB as first-line therapy 2, 1
• Target BP <130/80 mmHg 2, 3

Chronic kidney disease or albuminuria (UACR ≥30 mg/g):

• Initiate ACE inhibitor or ARB at maximum tolerated dose to reduce progressive kidney disease 2, 1
• Monitor serum creatinine and potassium at least annually 2

Coronary artery disease:

• Use ACE inhibitor or ARB as first-line therapy 2, 1
• Add beta-blocker if history of myocardial infarction, active angina, or heart failure with reduced ejection fraction 1

Pregnancy or planning pregnancy:

• Absolutely contraindicated: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors (risk of fetal injury and death) 3
• Use calcium channel blockers or methyldopa instead 3

Blood Pressure Targets

• Adults <65 years: <130/80 mmHg 1, 3
• Adults ≥65 years: Systolic <130 mmHg if well-tolerated 1
• Diabetes, CKD, or established CVD: <130/80 mmHg 2, 3

Monitoring and Titration Strategy

Initial follow-up:

• Recheck BP in 1 month after initiating therapy 1, 3
• Monitor serum creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or diuretics 1, 3

Titration approach:

• If starting with monotherapy, titrate to full dose before adding a second agent 1, 3
• For lisinopril: increase from 10 mg to 20-40 mg daily (usual dosage range) 4
• For losartan: increase from 50 mg to 100 mg daily as needed 5
• Achieve BP control within 3 months 2, 3

If BP remains uncontrolled on two drugs:

• Escalate to three-drug combination: ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic 3
• If still uncontrolled, add spironolactone 25 mg daily 3

Critical Pitfalls to Avoid

Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with BP ≥140/90 mmHg—current evidence favors simultaneous initiation 1, 3

Avoid hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics have superior cardiovascular outcome data 1, 3

Do not combine ACE inhibitors with ARBs or use with direct renin inhibitors—increased risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 2

Monitor for adverse effects:

• Hyperkalemia with ACE inhibitors/ARBs (especially in CKD) 2, 1
• Hypokalemia with diuretics 1, 3
• Angioedema with ACE inhibitors (contraindication to future use) 3
• Acute renal failure with ACE inhibitors/ARBs in bilateral renal artery stenosis 3

Avoid beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease, post-MI) 3