What is the initial treatment approach for a patient with hypertension?

Initial Treatment Approach for Hypertension

For patients with confirmed hypertension (BP ≥140/90 mmHg), initiate immediate combination therapy with two first-line antihypertensive medications if BP is ≥150/90 mmHg, or start with monotherapy if BP is 130-150/90 mmHg, alongside mandatory lifestyle modifications. 1, 2

Confirming the Diagnosis

Before initiating treatment, confirm hypertension using validated automated upper arm cuff devices with appropriate cuff size, measuring BP in both arms and using the higher reading 3. Office BP ≥140/90 mmHg defines hypertension, but must be confirmed with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) 1, 3.

Step 1: Universal Lifestyle Modifications

All patients with BP >120/80 mmHg require lifestyle modifications regardless of whether pharmacotherapy is initiated. 1, 2 These interventions are not optional and should never be discontinued once drug therapy starts, as they are complementary and may reduce medication requirements 3.

Specific lifestyle interventions include:

• Dietary changes: Implement DASH or Mediterranean diet with sodium restriction and increased potassium intake 1, 3
• Weight reduction: Target BMI of 20-25 kg/m² for overweight patients 1
• Physical activity: At least 150 minutes of moderate aerobic activity per week plus resistance training 2-3 times weekly 1, 3
• Alcohol moderation: Maximum 2 units/day for men and 1 unit/day for women 1, 2
• Smoking cessation: Mandatory recommendation for all patients 1

Step 2: Pharmacotherapy Decision Algorithm

For BP 130-150/90 mmHg:

• Start with monotherapy using one first-line agent 1
• Initiate immediately if patient has high cardiovascular risk, existing CVD, diabetes, chronic kidney disease, or target organ damage 1, 2

For BP ≥150/90 mmHg:

• Start with combination therapy using two antihypertensive medications from different classes 1, 2
• Preferably use single-pill combinations to improve adherence 2, 3

Step 3: First-Line Medication Selection

The choice of initial medication depends on patient race and comorbidities:

For Non-Black Patients:

• Preferred initial combination: Low-dose ACE inhibitor or ARB + dihydropyridine calcium channel blocker 3
• Alternative combination: Thiazide-like diuretic + ACE inhibitor or ARB 2
• Monotherapy options: ACE inhibitor (lisinopril 10 mg/day), ARB (losartan 50 mg/day), thiazide-like diuretic, or calcium channel blocker 1, 4, 5

For Black Patients:

• Preferred initial combination: ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic 2, 3
• Monotherapy: Thiazide-type diuretic or calcium channel blocker (these are more effective as monotherapy in this population) 2

For Patients with Specific Comorbidities:

• Chronic kidney disease or albuminuria: ACE inhibitor or ARB as first-line 2
• Diabetes with albuminuria: ACE inhibitor or ARB mandatory 2
• Thoracic aortic disease: Beta-blockers preferred 2

Step 4: Dosing and Titration Strategy

• Start lisinopril at 10 mg once daily, titrate to 20-40 mg daily as needed (maximum 80 mg) 4
• Start losartan at 50 mg once daily, titrate to maximum 100 mg daily as needed 5
• Titrate dosage every 2-4 weeks until target BP is reached 1
• Maximize the dose of the first medication before adding a second agent to avoid underdosing 2

Step 5: Blood Pressure Targets

• Adults <65 years: Target <130/80 mmHg 1, 3
• Adults 65-85 years: Target systolic BP 120-129 mmHg if well tolerated 1
• Adults >85 years: Target systolic BP 130-139 mmHg if well tolerated 1
• Home BP monitoring target: <135/85 mmHg 2
• Initial goal: Reduce BP by at least 20/10 mmHg and achieve target within 3 months 3

Step 6: Monitoring Schedule

• Follow-up within 2-4 weeks initially to assess response and tolerability 3
• Monthly follow-up visits until target BP is reached 1, 2
• Monitor serum creatinine and potassium 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1, 2, 3
• Implement home BP monitoring for ongoing therapy guidance 1, 2

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB) as this is potentially harmful 1, 3
• Avoid beta-blockers as first-line therapy without specific cardiac indication, as they are less effective for stroke prevention 2
• Do not underdose medications before adding additional agents; titrate to maximum tolerated dose first 2
• Avoid clinical inertia: Immediate combination therapy is more effective than sequential monotherapy titration for patients with BP ≥150/90 mmHg 3
• ACE inhibitors, ARBs, and related agents are contraindicated in pregnancy and should be avoided in sexually active women of childbearing age without reliable contraception 1
• Continue antihypertensive therapy lifelong, even beyond 85 years of age if well tolerated 1