What is the initial treatment for hypertension?

Initial Treatment for Hypertension

Begin with lifestyle modifications immediately for all patients, and initiate pharmacologic therapy simultaneously with a two-drug combination (preferably a single-pill combination of a RAS blocker plus either a calcium channel blocker or thiazide-like diuretic) if blood pressure is ≥140/90 mmHg, or start with a single first-line agent if blood pressure is 130-139/80-89 mmHg in high-risk patients. 1, 2

Confirming the Diagnosis

Before initiating treatment, confirm hypertension using out-of-office measurements rather than relying solely on office readings 1, 2:

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

Lifestyle Modifications (Start Immediately for All Patients)

Implement these evidence-based interventions as they enhance drug efficacy and provide cardiovascular benefits 1, 2, 3:

• Dietary pattern: Follow DASH diet emphasizing 8-10 servings/day of fruits and vegetables, 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 through dietary sources 1, 2
• Weight reduction: 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 Decision Algorithm

For Blood Pressure 130-139/80-89 mmHg:

• High-risk patients (established CVD, chronic kidney disease, diabetes, target organ damage, or 10-year ASCVD risk ≥10%): Start single first-line agent immediately 1, 2
• Low-to-moderate risk patients: The 2024 ESC guidelines recommend starting pharmacotherapy simultaneously with lifestyle modifications rather than delaying 3-6 months 1

For Blood Pressure ≥140/90 mmHg:

• Start two antihypertensive agents simultaneously from different classes, preferably as a single-pill combination to improve adherence 1, 2

First-Line Pharmacologic Agents

Choose from four equally effective classes 1, 2, 3:

• ACE inhibitors (e.g., lisinopril 10 mg daily) 4
• ARBs (e.g., losartan 50 mg daily) 5
• Thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 1
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2

Specific Two-Drug Combinations for BP ≥140/90 mmHg:

For non-Black patients 6, 1:

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker, OR
• RAS blocker (ACE inhibitor or ARB) + thiazide-like diuretic

For Black patients 1, 2:

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

Special Population Considerations

Patients with Comorbidities:

• Diabetes or chronic kidney disease with albuminuria (UACR ≥30 mg/g): Use ACE inhibitor or ARB as first-line to reduce progressive kidney disease 1, 2
• Coronary artery disease: Use ACE inhibitor or ARB as first-line; add beta-blocker if history of myocardial infarction, active angina, or heart failure with reduced ejection fraction 1, 2
• Heart failure: Beta-blockers indicated in addition to other agents 1

Contraindications:

• Pregnancy or women planning pregnancy: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors are absolutely contraindicated due to fetal injury and death 1, 7

Blood Pressure Targets

• Most adults <65 years: <130/80 mmHg 1, 2
• Adults ≥65 years: Systolic <130 mmHg if well-tolerated 1, 2
• Patients with diabetes, CKD, or established CVD: <130/80 mmHg 1, 2
• European guidelines: Target systolic 120-129 mmHg for most adults when treatment is well tolerated 1

Monitoring and Follow-Up Strategy

• Recheck blood pressure in 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 1, 2
• Watch for hyperkalemia with ACE inhibitors/ARBs and hypokalemia with diuretics 1, 2
• Achieve BP control within 3 months with follow-up every 1-3 months until controlled 1

Titration Strategy

If starting with monotherapy, titrate to full dose of initial agent before adding a second drug 1, 2:

• Lisinopril: Increase from 10 mg to 20-40 mg daily 1, 4
• Losartan: Increase from 50 mg to 100 mg daily 1, 5

If BP not controlled with two drugs, escalate to three-drug combination (RAS blocker + calcium channel blocker + thiazide-like diuretic) 1

If BP not controlled with three drugs, add spironolactone 25 mg daily 1, 8

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for a 3-6 month trial of lifestyle modification alone in patients with BP ≥140/90 mmHg—current evidence favors simultaneous initiation 1
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics are preferred 1
• Do not use beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease, post-MI) 1
• Avoid ACE inhibitors in patients with history of angioedema 2
• Use thiazides cautiously in patients with gout unless on uric acid-lowering therapy 2