What is the initial treatment plan for a patient with newly diagnosed stage two hypertension?

Initial Treatment Plan for Stage 2 Hypertension

For newly diagnosed stage 2 hypertension (BP ≥140/90 mmHg), immediately initiate combination therapy with two antihypertensive agents from different classes plus lifestyle modifications, with follow-up in 1 month. 1, 2

Immediate Pharmacological Management

Start dual-agent therapy at the first visit with one of these preferred combinations: 1, 2

• ACE inhibitor (or ARB) + calcium channel blocker, OR
• ACE inhibitor (or ARB) + thiazide/thiazide-like diuretic 1

Use single-pill combination formulations when possible to improve adherence. 1

Specific Dosing Examples:

• Lisinopril 10 mg daily (can start at 5 mg if patient has low systolic BP 100-120 mmHg) combined with either amlodipine 5 mg or hydrochlorothiazide 12.5 mg 3, 4
• Titrate to full doses before adding a third agent: lisinopril up to 40 mg, amlodipine up to 10 mg, or hydrochlorothiazide up to 25 mg 3, 4

Race-Based Considerations:

• For Black patients: Preferred initial combination is ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide diuretic 1
• For non-Black patients: ACE inhibitor or ARB + calcium channel blocker or thiazide diuretic 1

Concurrent Lifestyle Modifications (Mandatory, Not Optional)

Initiate all of the following interventions simultaneously with medications: 1, 2

• Weight loss: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• DASH or Mediterranean diet: Emphasize fruits, vegetables, low-fat dairy, reduced saturated fat 1, 4, 5
• Sodium restriction: Limit to <2,300 mg/day (ideally <1,500 mg/day) 4, 5
• Potassium supplementation: Increase dietary potassium through food sources 4, 5
• Alcohol limitation: Maximum 100 g/week of pure alcohol (approximately 7-14 standard drinks/week for men, fewer for women), preferably avoid entirely 1
• Physical activity: 150 minutes/week of moderate-intensity aerobic exercise plus resistance training 2-3 times/week 1
• Smoking cessation: Mandatory referral to cessation programs if applicable 1

Follow-Up Schedule

• Recheck BP in 1 month after initiating therapy 1, 2
• Monitor electrolytes and renal function 2-4 weeks after starting ACE inhibitor, ARB, or diuretic 1
• Continue monthly follow-up until BP is controlled, then every 1-3 months 2

Blood Pressure Target

Target systolic BP 120-129 mmHg (if well tolerated) or at minimum <140/90 mmHg. 1, 2, 4

Escalation Strategy if Uncontrolled

If BP remains ≥140/90 mmHg on two-drug combination after 1 month: 1, 2

• Add a third agent (typically the missing component of the triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1, 2
• Achieve BP control within 3 months of initial diagnosis 1, 2

If still uncontrolled on three agents: 2

• Add spironolactone as fourth-line agent 2
• If spironolactone contraindicated or not tolerated: consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Critical Pitfalls to Avoid

Do not use monotherapy for stage 2 hypertension—this is inadequate and delays BP control. 1, 2

Never combine two RAS blockers (ACE inhibitor + ARB + renin inhibitor)—this is potentially harmful. 1

Do not delay medication initiation while attempting lifestyle modifications alone in stage 2 hypertension—both must start immediately. 1

For very high BP (≥180/110 mmHg): Initiate treatment within 1 week with prompt evaluation for target organ damage. 1

Special Considerations

• If patient has diabetes, CKD, or albuminuria (UACR ≥30 mg/g): Prioritize ACE inhibitor or ARB as one of the initial agents 2
• If patient has coronary artery disease: Prefer ACE inhibitor or ARB 2
• If patient is pregnant or planning pregnancy: Avoid ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists entirely 2
• Patients ≥85 years or with moderate-to-severe frailty: May consider starting with single agent rather than combination therapy 1