What is the recommended treatment for systemic hypertension?

Recommended Treatment for Systemic Hypertension

For most adults with confirmed hypertension, initiate combination therapy immediately with two first-line agents—specifically a RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic—preferably as a single-pill combination, targeting systolic blood pressure of 120-129 mmHg if tolerated. 1, 2, 3

Blood Pressure Targets

• Target systolic BP 120-129 mmHg and diastolic BP <80 mmHg for adults under 65 years if well tolerated 1, 2, 3
• Target systolic BP 130-139 mmHg for adults ≥65 years 3
• Target <130/80 mmHg for high-risk patients with diabetes, chronic kidney disease, or established cardiovascular disease 1, 3

Pharmacological Treatment Algorithm

Step 1: Initial Two-Drug Combination

• Start with RAS blocker (ACE inhibitor or ARB) PLUS either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic 1, 2, 3
• Prescribe as a single-pill fixed-dose combination whenever possible to enhance adherence 2, 3
• ACE inhibitors (such as lisinopril) are FDA-approved for hypertension treatment and lower the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions 4

Step 2: Escalation to Three-Drug Combination

• If BP remains uncontrolled after 3 months, add the third agent to create a three-drug combination of RAS blocker, dihydropyridine calcium channel blocker, AND thiazide/thiazide-like diuretic 2

Step 3: Resistant Hypertension (Fourth Agent)

• Add low-dose spironolactone (mineralocorticoid receptor antagonist) as the fourth agent 1, 3
• If spironolactone is not tolerated, consider eplerenone, amiloride, higher-dose thiazide/thiazide-like diuretic, loop diuretic, bisoprolol, or doxazosin 1

Special Population Considerations

Black Patients

• Initial therapy should include a diuretic or calcium channel blocker, either in combination or with a RAS blocker 1, 3
• For patients from Sub-Saharan Africa, use calcium channel blocker combined with either a thiazide diuretic or RAS blocker 1

Patients with Chronic Kidney Disease

• Target systolic BP 120-129 mmHg if eGFR >30 mL/min/1.73 m² and tolerated 1, 2
• Include a RAS blocker when albuminuria or proteinuria is present, as RAS blockers are more effective at reducing albuminuria than other antihypertensive agents 1, 2, 3

Patients with Heart Failure

• For HFrEF/HFmrEF: Use ACE inhibitor (or ARB if ACE inhibitor not tolerated) or ARNi, beta-blocker, MRA, and SGLT2 inhibitors 1
• For HFpEF: SGLT2 inhibitors are recommended to improve outcomes; ARBs and/or MRAs may be considered to reduce heart failure hospitalizations 1, 2
• Target BP <130/80 mmHg but >120/70 mmHg 1, 3

Patients with Coronary Artery Disease

• Use RAS blockers and beta-blockers as first-line agents, with or without calcium channel blockers 1, 3
• Target BP <130/80 mmHg (<140/80 in elderly patients) 1

Patients with Previous Stroke/TIA

• Target systolic BP 120-130 mmHg 1, 3
• Use RAS blockers, calcium channel blockers, and diuretics as first-line agents 1, 3

Patients with Diabetes

• Initiate treatment at BP ≥140/90 mmHg and target <130/80 mmHg 1, 3
• Use RAS inhibitor combined with calcium channel blocker and/or thiazide-like diuretic 3

Essential Lifestyle Modifications

All patients should implement the following lifestyle changes, which can reduce systolic BP by approximately 5-10 mmHg 5, 6:

• Weight reduction to target BMI 20-25 kg/m² and waist circumference <94 cm for men or <80 cm for women 2, 3
• Sodium restriction to <2,300 mg/day 1, 2, 3, 5
• Dietary pattern: 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products (DASH diet) 2, 3, 5
• Physical activity: Minimum 150 minutes/week of moderate-intensity aerobic activity or 75 minutes/week of vigorous activity, plus resistance training 2-3 times weekly 3
• Alcohol limitation: ≤2 drinks/day for men and ≤1 drink/day for women 2, 3
• Complete tobacco cessation with referral to smoking cessation programs 2, 3
• Elimination of sugar-sweetened beverages and restriction of free sugar to maximum 10% of energy intake 2

Critical Pitfalls to Avoid

• Never combine two RAS blockers (e.g., ACE inhibitor plus ARB) due to increased adverse effects without additional benefit 3
• Do not delay initiation of combination therapy in favor of monotherapy—this outdated approach delays BP control 3
• Avoid prescribing multiple separate pills when single-pill combinations are available, as this significantly reduces adherence 3
• Do not use beta-blockers as first-line therapy except in specific conditions (coronary artery disease, heart failure, post-MI) 3

Monitoring and Follow-Up

• Achieve target BP within 3 months of treatment initiation 2, 3
• Use both office and home BP readings for regular monitoring 3
• Monitor renal function and potassium at least annually when using ACE inhibitor, ARB, or diuretic 2, 3
• Continue lifelong BP-lowering treatment if well tolerated, even beyond age 85 3
• Medication timing should be at the most convenient time to establish routine and improve adherence 2

When to Start with Lifestyle Modifications Alone

For patients with high-normal BP or grade 1 hypertension without high cardiovascular risk factors, lifestyle modifications should be tried first for 3-6 months; if BP remains uncontrolled, then initiate pharmacological therapy 5. However, for most patients with confirmed hypertension, immediate combination pharmacological therapy is recommended alongside lifestyle modifications 1, 2, 3.