What is the initial management for a patient with hypertension?

Initial Management of Hypertension

For a patient with elevated blood pressure ≥140/90 mmHg, initiate both lifestyle modifications AND pharmacological therapy simultaneously with a two-drug combination of a RAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide-like diuretic, preferably as a single-pill combination. 1

Confirming the Diagnosis

Before starting treatment, confirm hypertension using out-of-office measurements 1, 2:

• Home BP monitoring: ≥135/85 mmHg confirms hypertension 1
• 24-hour ambulatory BP monitoring: ≥130/80 mmHg confirms hypertension 1
• Measure BP in both arms at first visit and use the arm with higher readings 2

Critical caveat: Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with confirmed BP ≥140/90 mmHg—current evidence favors simultaneous initiation of both interventions. 1

Pharmacological Therapy: First-Line Approach

For Non-Black Patients

Start with a two-drug combination 1, 2:

• Option 1: ACE inhibitor (lisinopril 10 mg daily) + dihydropyridine calcium channel blocker (amlodipine 5 mg daily) 1, 3
• Option 2: ACE inhibitor (lisinopril 10 mg daily) + thiazide-like diuretic (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide) 1
• Option 3: ARB (losartan 50 mg daily) + calcium channel blocker or thiazide-like diuretic 1, 4

Prefer single-pill combinations to improve medication adherence 1

For Black Patients

The evidence shows reduced response to ACE inhibitors as monotherapy 1:

• Recommended: ARB + dihydropyridine calcium channel blocker 1, 2
• Alternative: Calcium channel blocker + thiazide-like diuretic 1

Special Population Considerations

Patients with diabetes or chronic kidney disease:

• Must include an ACE inhibitor or ARB as part of initial therapy 5, 2
• Target BP <130/80 mmHg 5

Patients with albuminuria (UACR ≥30 mg/g):

• Initial treatment must include an ACE inhibitor or ARB to reduce progressive kidney disease risk 1

Patients with coronary artery disease:

• ACE inhibitors or ARBs are first-line 1

Patients with heart failure:

• Include ACE inhibitor or ARB plus beta-blocker 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

Lifestyle Modifications (Initiated Simultaneously)

These interventions enhance drug efficacy and should be implemented alongside medications 1, 6, 7:

Dietary interventions:

• DASH diet pattern: Emphasizing fruits and vegetables (8-10 servings/day), low-fat dairy products (2-3 servings/day) 1, 7
• Sodium restriction: <2,300 mg/day 1
• Increased potassium intake through fruits and vegetables 1
• Eliminate table salt use 1

Weight management:

• Weight loss for overweight individuals through caloric restriction 1, 7
• Target healthy body mass index 7

Physical activity:

• At least 150 minutes of moderate-intensity aerobic activity per week 1, 7

Alcohol moderation:

• ≤2 drinks/day for men, ≤1 drink/day for women 1, 7

Smoking cessation:

• Recommended for all patients 1

Blood Pressure Targets

For most adults <65 years:

• Target <130/80 mmHg 1, 2, 7

For adults 65-85 years:

• Target systolic BP 120-129 mmHg if well tolerated 1, 2

For patients with diabetes, CKD, or established cardiovascular disease:

• Target <130/80 mmHg 5, 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
• Monitor for hypokalemia when using diuretics 1

BP control timeline:

• Achieve target BP within 3 months 1, 2
• Follow-up every 1-3 months until BP is controlled 1

Titration strategy if BP not controlled:

1. Increase to full dose of initial agents before adding third drug 1
2. If still uncontrolled, escalate to three-drug combination (ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic) 1
3. If resistant to three drugs, add spironolactone 25 mg daily 1, 2

Common Pitfalls to Avoid

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