What is the first line management for hypertension?

First-Line Management for Hypertension

For most adults with hypertension, first-line management consists of lifestyle modifications combined with pharmacological therapy using one of four equally effective medication classes: thiazide or thiazide-like diuretics (preferably chlorthalidone or indapamide), ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers (such as amlodipine). 1, 2

Lifestyle Modifications (Foundation for All Patients)

Lifestyle changes should be implemented for all patients with blood pressure >120/80 mmHg and are partially additive with pharmacological therapy 3, 4:

• Weight loss to achieve BMI 20-25 kg/m² if overweight or obese 1, 2
• Dietary sodium restriction to <2,300 mg/day with increased potassium intake 1, 2
• DASH or Mediterranean dietary pattern emphasizing fruits, vegetables, and low-fat dairy products 1, 4
• Regular aerobic exercise ≥150 minutes of moderate-intensity activity per week plus resistance training 2-3 times weekly 1, 2
• Alcohol moderation to ≤2 drinks/day for men and ≤1 drink/day for women, with <100g/week of pure alcohol preferred 1, 2
• Smoking cessation for all patients 1

Pharmacological Therapy Initiation Thresholds

The decision to start medication depends on blood pressure level and cardiovascular risk 1:

• BP ≥140/90 mmHg: Initiate pharmacological therapy in most patients 1
• BP ≥130/80 mmHg: Initiate pharmacological therapy in high-risk patients (established CVD, diabetes, chronic kidney disease, or ≥10% 10-year ASCVD risk) 1, 4
• BP 130-139/80-89 mmHg with low CVD risk: Lifestyle modifications alone for 3-6 months before considering medication 1

First-Line Medication Classes (Equally Effective)

All four classes reduce cardiovascular morbidity and mortality equivalently 1, 4:

1. Thiazide or thiazide-like diuretics (chlorthalidone or indapamide preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular event reduction) 3, 1
2. ACE inhibitors (e.g., lisinopril, enalapril) 1, 4
3. ARBs (e.g., candesartan, losartan) 1, 4
4. Dihydropyridine calcium channel blockers (amlodipine preferred as long-acting agent) 3, 1

Initial Treatment Strategy Based on BP Severity

• Stage 1 hypertension (130-139/80-89 mmHg): Start with single agent from one of the four first-line classes 3, 1
• Stage 2 hypertension (≥140/90 mmHg or ≥160/100 mmHg): Initiate two medications from different classes immediately, preferably as single-pill combination to improve adherence 3, 1
• Use fixed-dose combinations when multiple medications are needed to enhance adherence 3

Special Population Considerations (Mandatory Modifications)

Certain patient characteristics mandate specific first-line choices 1, 2:

Patients with Albuminuria (UACR ≥30 mg/g)

• ACE inhibitor or ARB is mandatory first-line therapy at maximum tolerated dose to reduce proteinuria and slow kidney disease progression 3, 1, 2
• This applies to both diabetic and non-diabetic kidney disease 3

Patients with Coronary Artery Disease

• ACE inhibitor or ARB should be selected as first-line therapy 3, 1, 2

Black Patients

• Calcium channel blockers or thiazide diuretics are more effective than ACE inhibitors or ARBs when used as monotherapy 1, 5
• However, if albuminuria is present, ACE inhibitor or ARB remains mandatory 1

Patients with Heart Failure with Reduced Ejection Fraction (HFrEF)

• Use medications with compelling indications for HF: ACE inhibitors, ARBs, angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists, diuretics, or GDMT beta blockers (carvedilol, metoprolol succinate, bisoprolol) 3
• Avoid nondihydropyridine calcium channel blockers (verapamil, diltiazem) as they have myocardial depressant activity and worsen outcomes 3

Patients with Heart Failure with Preserved Ejection Fraction (HFpEF)

• Diuretics for volume overload control 3
• ACE inhibitors or ARBs plus beta blockers after volume management 3

Blood Pressure Targets

• <130/80 mmHg for most adults <65 years 1, 2, 4
• Systolic BP <130 mmHg for adults ≥65 years 1, 2, 4
• Target systolic BP 120-129 mmHg if well tolerated 2

Titration and Escalation Strategy

If BP remains uncontrolled 2:

1. Two-drug combination: RAS blocker (ACE inhibitor or ARB) + either dihydropyridine calcium channel blocker or thiazide-like diuretic
2. Three-drug combination: RAS blocker + calcium channel blocker + thiazide-like diuretic
3. Four-drug regimen: Add mineralocorticoid receptor antagonist (spironolactone) and refer to hypertension specialist 3, 2

Critical Monitoring Requirements

• Monitor serum creatinine and potassium within 7-14 days after initiating ACE inhibitors, ARBs, or diuretics, then at least annually 3, 1, 2
• Follow-up visits 7-14 days after medication initiation or dose changes 1, 2
• Goal: achieve BP target within 3 months 2
• Monthly visits until BP target achieved 3

Important Contraindications and Caveats

Never Combine Certain Medications

• Never combine ACE inhibitors with ARBs as this increases adverse effects (hyperkalemia, syncope, acute kidney injury) without additional cardiovascular benefit 3, 1, 2
• Never combine ACE inhibitor or ARB with direct renin inhibitor 2

Pregnancy Considerations

• ACE inhibitors and ARBs are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential not using reliable contraception 1, 2

Hyperkalemia Risk

• Adding mineralocorticoid receptor antagonists to ACE inhibitor or ARB increases hyperkalemia risk, requiring regular monitoring 3, 2

Continuation Despite Declining Renal Function

• Continue ACE inhibitor or ARB therapy even as kidney function declines to eGFR <30 mL/min/1.73 m² for cardiovascular benefit 3, 2

Implementation Strategies for Better Control

• Use 90-day refills instead of 30-day when allowed 3
• Employ telehealth strategies and home BP monitoring for medication titration 3
• Implement team-based care with multidisciplinary approach 3
• Screen for social determinants of health and medication adherence barriers 3