What is the first-line treatment for hypertension?

From the Guidelines

The first line treatment for hypertension should typically involve lifestyle modifications along with medication therapy, with thiazide diuretics, calcium-channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers recommended as initial pharmacological therapy. For most patients, the choice of initial medication depends on patient characteristics, including age, race, and comorbidities.

• Thiazide diuretics (like chlorthalidone 12.5-25mg daily) and calcium-channel blockers are the preferred options for first-line therapy in most U.S. adults because of their efficacy, as noted in the 2017 American College of Cardiology/American Heart Association hypertension guideline 1.
• In black patients, including those with diabetes, thiazide diuretics and calcium-channel blockers are recommended as first-line agents, whereas β-blockers and renin–angiotensin system inhibitors are less effective at lowering BP, as stated in the same guideline 1.
• Lifestyle modifications are essential and include reducing sodium intake to less than 2.3g daily, adopting the DASH diet rich in fruits and vegetables, regular physical activity (150 minutes of moderate-intensity exercise weekly), limiting alcohol consumption, maintaining healthy weight, and smoking cessation.
• These medications work through different mechanisms: diuretics reduce blood volume, ACE inhibitors and ARBs block the renin-angiotensin system, and calcium channel blockers relax blood vessel walls.
• Treatment should be monitored regularly, with dose adjustments or additional medications added if blood pressure targets (typically <130/80 mmHg) are not achieved within 3-6 months, as recommended in the prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline 1.

From the Research

First-Line Treatment of Hypertension

• The first-line treatment for hypertension includes lifestyle modification, such as weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 2.
• When drug therapy is required, first-line therapies are thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blockers 2, 3.
• Guidelines recommend thiazide diuretics as preferred first-line monotherapy, but only 50% of patients will respond adequately to this therapy and the rest will require two or more antihypertensive agents to achieve blood pressure goals 4.
• Combination therapy with at least two potent medications, such as a renin-angiotensin-aldosterone system blocker and a calcium channel blocker, may be more effective in reducing blood pressure and preventing cardiovascular events 5.

Classes of Drugs for Hypertension

• Thiazide diuretics: reduce mortality, stroke, coronary heart disease, and total cardiovascular events 3.
• Angiotensin-converting enzyme inhibitors: reduce mortality, stroke, coronary heart disease, and total cardiovascular events 3.
• Calcium channel blockers: reduce stroke and total cardiovascular events, but the evidence is of lower quality 3.
• Angiotensin receptor blockers: may be similarly effective to ACE inhibitors, but the evidence is limited 4, 6.
• Beta-blockers: did not reduce mortality or coronary heart disease, but reduced stroke and total cardiovascular events 3.

Combination Therapy

• Combination therapy with an angiotensin II receptor blocker, a calcium channel blocker, and a thiazide diuretic may be a rational approach for patients who require triple therapy 6.
• Fixed-dose combinations of antihypertensive drugs may improve blood pressure control and aid compliance with long-term therapy 6.
• Combination pills are popular with patients and increase compliance with therapy 5.