What is the initial treatment approach for essential hypertension?

Initial Treatment Approach for Essential Hypertension

For essential hypertension, begin immediately with both lifestyle modifications and pharmacological therapy simultaneously when blood pressure is ≥140/90 mmHg, using a two-drug combination of a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide-like diuretic, preferably as a single-pill combination. 1

Confirming the Diagnosis

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

• Home blood pressure monitoring showing ≥135/85 mmHg, or 1
• 24-hour ambulatory monitoring showing ≥130/80 mmHg 1
• Measure blood pressure in both arms at the first visit and use the arm with higher readings for subsequent measurements 2

Lifestyle Modifications (Start Immediately)

Implement these evidence-based interventions alongside medications, as they enhance drug efficacy 1:

• DASH diet pattern: 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 1
• Sodium restriction: Limit intake to <2,300 mg/day and eliminate table salt use 1
• Weight reduction: For overweight patients through caloric restriction 1
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1
• Smoking cessation: Mandatory for all patients 1

Initial Pharmacological Therapy

Standard Approach (Non-Black Patients)

Start with a two-drug combination when BP is ≥140/90 mmHg 1:

Option 1 (Preferred):

• ACE inhibitor (lisinopril 10 mg daily) 3 + thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) 4
• Chlorthalidone is superior to hydrochlorothiazide due to longer half-life and better cardiovascular outcomes 1

Option 2:

• ACE inhibitor (lisinopril 10 mg daily) 3 + dihydropyridine calcium channel blocker (amlodipine 5 mg daily) 1

Option 3:

• ARB + dihydropyridine calcium channel blocker 1

Black Patients

Initial therapy should include 1:

• ARB + dihydropyridine calcium channel blocker, OR
• Calcium channel blocker + thiazide-like diuretic
• This is due to reduced response to ACE inhibitors as monotherapy in this population 1

Single-Pill Combinations

Strongly prefer single-pill combinations to improve medication adherence 1. The European Society of Cardiology recommends this approach for all patients starting with two drugs 5.

Blood Pressure Targets

• Most adults <65 years: <130/80 mmHg 2
• Adults 65-85 years: Systolic BP 120-129 mmHg if well tolerated 2
• Patients with diabetes or CKD: <130/80 mmHg 5, 1

Titration Strategy

Follow-up timeline 1:

• Recheck blood pressure in 1 month after initiating therapy
• Goal is to achieve BP control within 3 months 2
• If BP not controlled with two drugs, escalate to three-drug combination (add the third class not yet used) 1

Medication titration 1:

• Increase ACE inhibitor to full dose (lisinopril 20-40 mg daily) before adding additional agents 3
• If still uncontrolled, add the third drug class
• For resistant hypertension after optimizing three drugs, add spironolactone 25 mg daily 1

Special Population Considerations

Patients with specific comorbidities require tailored approaches:

• Coronary artery disease: ACE inhibitors or ARBs as first-line 1
• Albuminuria (UACR ≥30 mg/g): Must include ACE inhibitor or ARB to reduce progressive kidney disease 1
• Heart failure: Add beta-blockers to the regimen 1
• Pregnancy or planning pregnancy: Absolutely contraindicated: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors 1, 2

Monitoring Requirements

Laboratory monitoring 1:

• Check serum creatinine and potassium 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists
• Monitor for hypokalemia when using diuretics

Critical Pitfalls to Avoid

Do not delay pharmacotherapy for a trial of lifestyle modifications alone when BP is ≥140/90 mmHg 1. The outdated approach of waiting 3-6 months for lifestyle changes is no longer recommended by current guidelines 1. This represents a major shift from older guidelines 5 that suggested observation periods for patients with diastolic BP 100-109 mmHg.

Avoid beta-blockers as initial therapy unless specific indications exist (heart failure, coronary disease) 1. Multiple guidelines now restrict their use as first-line agents 5.

Do not use hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics have superior cardiovascular outcomes 1.

Avoid ACE inhibitors in patients with history of angioedema or bilateral renal artery stenosis 1.