What is the initial treatment for newly diagnosed hypertension?

Initial Treatment for Newly Diagnosed Hypertension

For newly diagnosed hypertension, initiate both lifestyle modifications and pharmacologic therapy simultaneously with a single antihypertensive agent (ACE inhibitor, ARB, thiazide-like diuretic, or calcium channel blocker) for blood pressure 130-150/80-90 mmHg, or start with two-drug combination therapy for blood pressure ≥150/90 mmHg. 1, 2

Confirming the Diagnosis

• Before initiating treatment, confirm hypertension using out-of-office measurements with home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg). 1
• Blood pressure should be measured using the appropriate size cuff with the patient seated and relaxed, confirmed on at least three separate days. 3

Lifestyle Modifications (Initiate Immediately)

All patients with blood pressure >120/80 mmHg should begin comprehensive lifestyle changes alongside any pharmacologic therapy: 1, 2

• Dietary interventions: Follow the DASH eating pattern with 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products, and sodium restriction to <2,300 mg/day (ideally <1,500 mg/day). 1, 2, 4
• Weight management: Achieve and maintain healthy body mass index through caloric restriction if overweight. 1, 4
• Physical activity: Engage in at least 150 minutes of moderate-intensity aerobic activity per week. 1, 4
• Alcohol moderation: Limit intake to ≤2 drinks/day for men and ≤1 drink/day for women. 1, 4
• Smoking cessation: Recommend for all patients. 1

Pharmacologic Therapy Selection

For Blood Pressure 130-150/80-90 mmHg (Stage 1-2 Hypertension)

Start with a single first-line antihypertensive agent: 1, 2

• Preferred initial agents (choose one):
  • ACE inhibitor: Lisinopril 10 mg once daily (usual range 20-40 mg/day, maximum 80 mg/day) 5, 4
  • ARB: Losartan 50 mg once daily (can increase to 100 mg/day) 6, 4
  • Thiazide-like diuretic: Chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 1, 4
  • Calcium channel blocker: Amlodipine 5 mg once daily 4, 7

For Blood Pressure ≥150/90 mmHg (Stage 2 Hypertension)

Initiate two-drug combination therapy from different classes, preferably as a single-pill combination: 1, 2

• Recommended combinations:

  • ACE inhibitor or ARB + thiazide-like diuretic 1, 2
  • ACE inhibitor or ARB + dihydropyridine calcium channel blocker 1, 2
  • Calcium channel blocker + thiazide-like diuretic 1

• Rationale: Two-drug therapy achieves blood pressure control faster, improves medication adherence, and reduces cardiovascular risk more rapidly than sequential monotherapy. 1

Special Population Considerations

Black Patients

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

Patients with Comorbidities

• Coronary artery disease: ACE inhibitors or ARBs as first-line therapy. 1
• Chronic kidney disease or albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB to reduce progressive kidney disease risk. 1, 2
• Heart failure: Beta-blockers indicated in addition to other agents. 1
• Diabetes: Target blood pressure <130/80 mmHg; ACE inhibitor or ARB preferred. 1

Pregnancy or Women Planning Pregnancy

• Absolutely contraindicated: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors due to fetal injury and death risk. 1, 2
• Use calcium channel blockers or methyldopa instead. 1

Monitoring and Follow-Up

• Laboratory monitoring: Check serum creatinine and potassium levels 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 1, 2
• Blood pressure reassessment: Recheck in 1 month after initiating therapy. 1
• Titration strategy: If blood pressure goal not achieved within 3 months, increase to full dose of initial agent before adding a second medication. 1
• Target blood pressure: <130/80 mmHg for most adults <65 years; <130 mmHg systolic for adults ≥65 years. 1, 2, 4

Common Pitfalls to Avoid

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

Escalation for Inadequate Response

If blood pressure remains uncontrolled after optimizing initial therapy:

• Step 1: Increase initial agent to maximum tolerated dose. 1
• Step 2: Add a second agent from a different class (if not already on combination therapy). 1
• Step 3: Add a third agent to create the standard three-drug combination: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic. 1
• Step 4: Add low-dose spironolactone 25 mg daily only after optimizing the three-drug combination. 1