Initial Treatment for Stage 1 Hypertension (140/90 mmHg)
For a first-time patient with blood pressure of 140/90 mmHg, initiate both lifestyle modifications immediately and start single-drug pharmacologic therapy promptly. 1
Immediate Pharmacologic Treatment
Begin single-drug antihypertensive therapy at the time of diagnosis for blood pressure 140/90 mmHg. 1 This represents stage 1 hypertension (140-159/90-99 mmHg), which warrants prompt pharmacologic intervention alongside lifestyle changes rather than a trial of lifestyle modification alone.
First-Line Medication Selection
Choose from these evidence-based first-line agents: 1, 2
For non-Black patients: Start with an ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily) 1, 2
For Black patients: Start with a thiazide-like diuretic (e.g., chlorthalidone 12.5-25 mg daily) or dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily) 1, 2
Alternative first-line options for any patient: Thiazide-like diuretics (chlorthalidone or indapamide preferred over hydrochlorothiazide) or dihydropyridine calcium channel blockers 1, 2
Important distinction: Blood pressure ≥160/100 mmHg requires starting with two medications or a single-pill combination immediately, but 140/90 mmHg can begin with monotherapy. 1
Concurrent Lifestyle Modifications
Implement all of the following lifestyle interventions simultaneously with medication: 1, 2
Dietary sodium restriction: Reduce intake to <2,300 mg/day (ideally <2,000 mg/day) 1, 2
DASH diet pattern: Increase fruits and vegetables to 8-10 servings per day, emphasize whole grains, low-fat dairy, and lean proteins 1, 3
Potassium supplementation: Increase dietary potassium intake through food sources 1, 2
Weight reduction: If overweight or obese, achieve caloric restriction targeting BMI 20-25 kg/m² 1, 2
Physical activity: Regular aerobic exercise (at least 150 minutes/week of moderate-intensity activity) 1, 2
Alcohol moderation: Limit to <100 g/week or eliminate entirely 1, 2
These lifestyle changes can provide additive blood pressure reductions of 10-20 mmHg and enhance medication effectiveness. 1, 3
Blood Pressure Targets and Monitoring
Target BP: <130/80 mmHg for most adults under 65 years; <130 mmHg systolic for adults ≥65 years 2, 4
Minimum acceptable target: <140/90 mmHg if lower targets not achievable 1, 4
Timeline: Achieve target blood pressure within 3 months of initiating therapy 5
Follow-up schedule: Reassess within 2-4 weeks after starting medication to evaluate response and check for adverse effects 5
Home BP monitoring: Implement to confirm diagnosis and track treatment response (home BP ≥135/85 mmHg confirms hypertension) 5, 4
Medication Titration Strategy
If blood pressure remains uncontrolled on initial monotherapy: 1, 5
First step: Optimize the dose of the initial medication to maximum recommended dose
Second step: Add a second agent from a different class (e.g., if started on ACE inhibitor, add calcium channel blocker or thiazide diuretic) 1, 5
Third step: If still uncontrolled on two medications at optimal doses, add a third agent to achieve triple therapy (typically ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1, 5
Critical Pitfalls to Avoid
Do not delay pharmacologic therapy for a trial of lifestyle modification alone at 140/90 mmHg—guidelines explicitly recommend prompt initiation of both interventions together 1
Do not combine ACE inhibitors with ARBs—this increases adverse events (hyperkalemia, syncope, acute kidney injury) without additional cardiovascular benefit 1
Do not use beta-blockers as first-line therapy unless compelling indications exist (post-MI, heart failure, angina) 5
Do not assume treatment failure without first confirming medication adherence, which is the most common cause of apparent resistance 5
Special Considerations for Diabetes
If the patient has diabetes: 1