What is the initial treatment approach for hypertension?

Initial Treatment Approach for Hypertension

For adults with newly diagnosed hypertension, begin lifestyle modifications immediately and initiate pharmacologic therapy with a single first-line agent (ACE inhibitor, ARB, thiazide-like diuretic, or calcium channel blocker) if blood pressure is 130-150/80-90 mmHg, or start with two agents simultaneously if blood pressure is ≥150/90 mmHg, targeting <130/80 mmHg. 1, 2

Confirming the Diagnosis

• Before initiating treatment, confirm hypertension using out-of-office measurements—either home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg)—rather than relying solely on office readings 2
• Blood pressure should be measured using appropriate technique with the patient relaxed and seated 3

Lifestyle Modifications (Foundation of All Treatment)

Implement these evidence-based interventions immediately for all patients with blood pressure >120/80 mmHg:

• Dietary pattern: Follow a DASH eating pattern emphasizing 8-10 servings/day of fruits and vegetables and 2-3 servings/day of low-fat dairy products 1, 2
• Sodium restriction: Limit intake to <2,300 mg/day (ideally <1,500 mg/day) 1, 2
• Potassium supplementation: Increase dietary potassium through fruits and vegetables 1, 2
• Weight management: Achieve caloric restriction if BMI ≥25 kg/m² 1, 2
• Physical activity: Engage in at least 150 minutes of moderate-intensity aerobic exercise per week 1, 2
• Alcohol moderation: Limit to ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• Smoking cessation: Recommend for all patients 1, 2

Pharmacologic Therapy Algorithm

For Blood Pressure 130-150/80-90 mmHg:

• Start with a single first-line agent from one of four equally effective classes 2, 4:

  • ACE inhibitor (e.g., lisinopril 10 mg daily) 5
  • ARB (e.g., losartan 50 mg daily) 6
  • Thiazide-like diuretic (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide) 1
  • Dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily) 2

• Initiate pharmacotherapy immediately if the patient has high cardiovascular risk: established CVD, chronic kidney disease, diabetes, target organ damage, or 10-year ASCVD risk ≥10% 2

For Blood Pressure ≥150/90 mmHg:

• Start with two antihypertensive agents simultaneously from different classes, preferably as a single-pill combination to improve adherence 1, 2
• Recommended two-drug combinations 1:
  • RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker, OR
  • RAS blocker + thiazide/thiazide-like diuretic

Special Population Considerations

Black Patients:

• Initial therapy should include ARB + calcium channel blocker or calcium channel blocker + thiazide-like diuretic due to reduced response to ACE inhibitors as monotherapy 1, 2

Patients with Diabetes or Chronic Kidney Disease:

• Use ACE inhibitor or ARB as first-line therapy to reduce risk of progressive kidney disease 1, 2

Patients with Coronary Artery Disease:

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

Pregnant Women or Those Planning Pregnancy:

• Absolutely contraindicated: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors due to fetal injury and death 1
• Use calcium channel blockers or methyldopa instead 1

Blood Pressure Targets

• <130/80 mmHg for most adults <65 years 1, 2
• Systolic <130 mmHg if well-tolerated for adults ≥65 years 2
• <130/80 mmHg for patients with diabetes, CKD, or established CVD 1

Monitoring and Titration Strategy

• Recheck blood pressure 1 month after initiating therapy 1, 2
• Monitor serum creatinine and potassium 7-14 days after starting or adjusting doses of ACE inhibitors, ARBs, or diuretics 2
• Watch for hyperkalemia with ACE inhibitors/ARBs and hypokalemia with diuretics 2
• If starting with monotherapy, titrate to full dose of initial agent before adding a second drug 1
• Achieve blood pressure control within 3 months, with follow-up every 1-3 months until controlled 1
• If blood pressure not controlled with two drugs, escalate to a three-drug combination (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for a lifestyle modification trial in patients with BP ≥140/90 mmHg—start both simultaneously 1
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics have superior cardiovascular outcome data 1
• Avoid beta-blockers as initial therapy unless a specific indication exists (heart failure, coronary disease, post-MI) 1
• Do not use ACE inhibitors in patients with history of angioedema or bilateral renal artery stenosis 1
• Use thiazides cautiously in patients with gout unless on uric acid-lowering therapy 1