What is the first-line treatment for hypertension?

From the Guidelines

The first line treatment for hypertension should include ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics, as these have demonstrated the most effective reduction of BP and CVD events, according to the 2024 ESC guidelines 1. When selecting a first-line treatment, the choice depends on patient characteristics, including age, race, and comorbidities.

• ACE inhibitors or ARBs are preferred in patients with diabetes or chronic kidney disease
• Calcium channel blockers or thiazide diuretics work better in Black patients
• Beta-blockers can be combined with other major BP-lowering drug classes when there are other compelling indications for their use, such as angina, post-myocardial infarction, heart failure with reduced ejection fraction, or for heart rate control 1. Lifestyle modifications are also essential and should be implemented alongside medication, including:
• Reducing sodium intake to less than 2.3g daily
• Regular physical activity (150 minutes of moderate exercise weekly)
• Limiting alcohol consumption
• Maintaining healthy weight
• Following the DASH diet rich in fruits, vegetables, and low-fat dairy. Treatment goals typically aim for blood pressure below 130/80 mmHg for most adults. Medication should be started at a low dose and titrated upward every 2-4 weeks until target blood pressure is achieved. 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 - all leading to reduced blood pressure and decreased cardiovascular risk. In patients receiving combination BP-lowering treatment, fixed-dose single-pill combination treatment is recommended, and if BP is not controlled with a two-drug combination, increasing to a three-drug combination is recommended, usually a RAS blocker with a dihydropyridine CCB and a thiazide/thiazide-like diuretic, and preferably in a single-pill combination 1.

From the FDA Drug Label

1. 1 Hypertension Losartan is indicated for the treatment of hypertension in adults and pediatric patients 6 years of age and older, to lower blood pressure. Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits Many patients will require more than 1 drug to achieve blood pressure goals. INDICATIONS & USAGE 1. 1 Hypertension Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure.

The first line treatment for hypertension is not explicitly stated in the provided drug labels. However, the labels do indicate that losartan 2 and lisinopril 3 are both used to treat hypertension in adults and pediatric patients.

• Losartan 2 and lisinopril 3 are both indicated for the treatment of hypertension.
• The labels suggest that control of high blood pressure should be part of comprehensive cardiovascular risk management.
• It is also mentioned that many patients will require more than 1 drug to achieve blood pressure goals. The choice of first-line treatment may depend on various factors, including the patient's specific condition, medical history, and other health considerations.

From the Research

First-Line Treatment for Hypertension

• The first-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 4.
• Lifestyle interventions, such as regular physical exercise, body weight management, and healthy dietary patterns, have been shown to have preventive and antihypertensive effects 5.
• When drug therapy is required, first-line therapies include thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blockers 4.
• Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been found to have similar efficacy in reducing blood pressure and cardiovascular outcomes, but angiotensin receptor blockers have fewer adverse events 6.
• Physical activity is a critical component of first-line treatment for elevated blood pressure or cholesterol, and has been shown to have extensive benefits, including improving blood pressure and blood cholesterol 7.

Medication Options

• Thiazide diuretics, such as hydrochlorothiazide or chlorthalidone, are commonly used as first-line therapy for hypertension 4.
• Calcium channel blockers, such as amlodipine, are also effective in lowering systolic blood pressure in elderly patients with hypertension 8.
• Angiotensin-converting enzyme inhibitors, such as enalapril, are effective in reducing blood pressure and cardiovascular outcomes, but may have more adverse events than angiotensin receptor blockers 6.
• Beta-blockers are relatively ineffective in lowering systolic blood pressure in elderly patients with hypertension and may have more side effects 8.

Lifestyle Modifications

• Weight loss has been shown to have a beneficial effect on blood pressure reduction 4.
• A healthy dietary pattern, including low sodium and high potassium intake, can help to reduce blood pressure 4.
• Regular physical activity has been shown to have extensive benefits, including improving blood pressure and blood cholesterol 7.
• Moderation or elimination of alcohol consumption can also help to reduce blood pressure 4.