What are the initial treatment recommendations for hypertension?

Initial Treatment Recommendations for Hypertension

For patients 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 formulation. 1, 2

Confirming the Diagnosis

• Confirm hypertension using out-of-office measurements before initiating treatment: home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory BP monitoring (≥130/80 mmHg). 1, 2
• Measure blood pressure at three separate visits using an appropriately sized cuff with the patient seated and relaxed. 3

Blood Pressure Thresholds and Treatment Intensity

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

• Consider starting with a single agent if the patient is at low-to-moderate cardiovascular risk. 2
• Preferred single agents include ACE inhibitors (lisinopril 10 mg daily), ARBs (losartan 50 mg daily), thiazide-like diuretics (chlorthalidone 12.5-25 mg daily), or dihydropyridine calcium channel blockers (amlodipine 5 mg daily). 1, 2, 4, 5

For BP ≥160/100 mmHg (Grade 2 hypertension):

• Start with a two-drug combination immediately. 1, 2
• Preferred combinations: RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker, OR RAS blocker + thiazide/thiazide-like diuretic. 1, 2
• Single-pill combinations are strongly preferred to improve medication adherence. 1, 2

First-Line Pharmacological Agents

Standard initial therapy (non-Black patients):

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

Black patients:

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

Important note on diuretic selection:

• Chlorthalidone is preferred over hydrochlorothiazide due to its longer half-life and superior cardiovascular outcome data. 1

Lifestyle Modifications (Initiated Simultaneously)

Dietary interventions:

• DASH eating pattern emphasizing fruits and vegetables (8-10 servings/day) and low-fat dairy products (2-3 servings/day). 1, 3
• Sodium restriction to <2,300 mg/day. 1, 3
• Increased potassium intake through dietary sources. 1, 3

Physical activity and weight management:

• At least 150 minutes of moderate-intensity aerobic exercise per week. 1, 3
• Weight loss for overweight individuals (target BMI 18.5-24.9 kg/m²). 1

Alcohol and smoking:

• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women. 1
• Smoking cessation for all patients. 1

Blood Pressure Targets

• Target BP <130/80 mmHg for most adults under 65 years. 1, 2
• Target systolic BP 120-129 mmHg if treatment is well tolerated. 1, 2
• For adults ≥65 years, target systolic BP 130-139 mmHg. 2

Special Population Considerations

Diabetes mellitus:

• ACE inhibitors or ARBs are recommended as first-line therapy. 2
• Target BP <130/80 mmHg. 2

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

• Initial treatment must include an ACE inhibitor or ARB. 1, 2

Coronary artery disease:

• ACE inhibitors or ARBs are recommended as first-line therapy. 1

Heart failure:

• Beta-blockers are indicated in addition to ACE inhibitors. 1

Pregnancy or planning pregnancy:

• ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors are absolutely contraindicated due to fetal injury and death. 1, 3

Monitoring and Follow-Up

• Check serum creatinine and potassium 7-14 days after initiating ACE inhibitors, ARBs, or diuretics. 1, 3
• Recheck blood pressure within 1 month after initiating therapy. 1
• Achieve BP control within 3 months, with follow-up every 1-3 months until controlled. 1
• Titrate to full dose of initial agents before adding a third medication. 1

Titration Strategy if BP Not Controlled

• Increase ACE inhibitor to full dose (lisinopril 20-40 mg daily) before adding additional agents. 1, 4
• If BP remains uncontrolled on two drugs, add a third agent from a different class (typically the missing component of the triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic). 1, 2
• If BP remains uncontrolled on three optimized drugs, add spironolactone 25 mg daily. 1, 2

Critical Pitfalls to Avoid

• Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with BP ≥140/90 mmHg—the 2024 ESC guidelines recommend simultaneous initiation of both lifestyle advice and BP-lowering medication. 1
• Avoid using beta-blockers as initial therapy unless a specific indication exists (heart failure, coronary disease, recent MI). 6, 1
• Never combine ACE inhibitors and ARBs together—this increases risk of adverse effects without additional benefit. 2
• Avoid ACE inhibitors in patients with history of angioedema or bilateral renal artery stenosis. 1
• Monitor for hyperkalemia when using ACE inhibitors/ARBs with spironolactone, especially in patients with CKD. 2