What are the initial treatment recommendations for hypertension?

Initial Treatment Recommendations for Hypertension

For patients with blood pressure 130-150/80-90 mmHg, begin with lifestyle modifications and a single first-line antihypertensive agent; for blood pressure ≥150/90 mmHg or ≥160/100 mmHg, initiate two-drug combination therapy simultaneously, preferably as a single-pill combination. 1, 2

Confirming the Diagnosis

Before initiating pharmacologic therapy, confirm hypertension using out-of-office measurements rather than relying solely on office readings 1, 2:

• Home blood pressure monitoring ≥135/85 mmHg, or 1, 3
• 24-hour ambulatory blood pressure monitoring ≥130/80 mmHg 1, 3

This step is critical to avoid treating white coat hypertension and ensures accurate diagnosis before committing patients to lifelong therapy.

Lifestyle Modifications (Initiate Immediately for All Patients)

Implement these evidence-based interventions alongside pharmacotherapy, as they enhance drug efficacy and may reduce medication requirements 1, 2, 4:

Dietary Changes:

• Follow a DASH eating pattern with 8-10 servings/day of fruits and vegetables 1, 2
• Consume 2-3 servings/day of low-fat dairy products 1, 2
• Restrict sodium intake to <2,300 mg/day (ideally <1,500 mg/day for hypertensive patients) 1, 2
• Increase dietary potassium intake 1, 2

Weight and Exercise:

• Achieve and maintain healthy body weight (BMI 18.5-24.9 kg/m²) through caloric restriction if overweight 1, 2
• Engage in at least 150 minutes of moderate-intensity aerobic exercise per week 1, 2

Substance Use:

• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• Complete smoking cessation 1, 2

Pharmacologic Therapy Algorithm

For Blood Pressure 130-150/80-90 mmHg:

Start with a single first-line agent from these four equally effective classes 1, 2, 4:

• ACE inhibitors (e.g., lisinopril 10 mg daily) 5
• ARBs (angiotensin receptor blockers) 1, 2
• Thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 1, 2
• Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2

Important caveat: Beta-blockers are NOT recommended as initial therapy unless specific indications exist (heart failure, coronary disease, recent myocardial infarction) 1, 3.

For Blood Pressure ≥150/90 mmHg or ≥160/100 mmHg:

Initiate two-drug combination therapy simultaneously from different classes, preferably as a single-pill combination to improve adherence 6, 1, 2:

Preferred combinations:

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker, or 1, 3
• RAS blocker (ACE inhibitor or ARB) + thiazide-like diuretic 1, 3

The European Society of Cardiology strongly recommends this approach for blood pressure ≥140/90 mmHg, while the American College of Cardiology recommends it when blood pressure is >20/10 mmHg above target 6, 1. Two-drug therapy achieves blood pressure control faster and reduces cardiovascular risk more rapidly than sequential monotherapy titration 1.

Special Population Considerations

Black Patients:

Initial therapy should include ARB + dihydropyridine calcium channel blocker or calcium channel blocker + thiazide-like diuretic due to reduced response to ACE inhibitors as monotherapy 1, 3, 2.

Patients with Diabetes:

Use ACE inhibitor or ARB as first-line therapy to reduce risk of progressive kidney disease 1, 3, 2.

Patients with Chronic Kidney Disease or Albuminuria (UACR ≥30 mg/g):

Initial treatment must include ACE inhibitor or ARB to reduce risk of progressive kidney disease 1, 3, 2.

Patients with Coronary Artery Disease:

Use ACE inhibitor or ARB as first-line therapy; add beta-blocker if history of myocardial infarction, active angina, or heart failure with reduced ejection fraction 1, 2.

Pregnant Women or Those Planning Pregnancy:

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

Blood Pressure Targets

• <130/80 mmHg for most adults <65 years 1, 2, 4
• Systolic <130 mmHg for adults ≥65 years (if well-tolerated) 1, 2
• 120-129/<80 mmHg for most adults when treatment is well tolerated (European Society of Cardiology target) 1, 3

Monitoring and Follow-Up

• Recheck blood pressure in 1 month after initiating therapy 1, 2
• Monitor serum creatinine and potassium 7-14 days after starting or adjusting doses of ACE inhibitors, ARBs, or diuretics 1, 2
• Watch for hyperkalemia with ACE inhibitors/ARBs and hypokalemia with diuretics 1, 2
• Titrate to full dose of initial agent before adding a second drug if starting with monotherapy 1, 2
• If blood pressure remains uncontrolled on two drugs, escalate to a three-drug combination (RAS blocker + calcium channel blocker + thiazide-like diuretic) 1, 3

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with blood pressure ≥140/90 mmHg, especially those with high cardiovascular risk 1, 2
• Avoid using hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics have superior cardiovascular outcomes 1
• Never combine ACE inhibitors and ARBs together, as this increases risk of adverse effects without additional benefit 3
• Avoid beta-blockers as initial therapy unless specific indications exist 1, 3
• Do not rely solely on office blood pressure measurements for diagnosis—confirm with home or ambulatory monitoring 1, 2