What is the initial treatment for hypertension?

Initial Treatment for Hypertension

Begin with lifestyle modifications immediately for all patients, and simultaneously initiate pharmacologic therapy with a single first-line agent (ACE inhibitor, ARB, thiazide-like diuretic, or dihydropyridine calcium channel blocker) if blood pressure is ≥140/90 mmHg, or start with two agents from different classes if blood pressure is ≥150/90 mmHg. 1, 2

Confirming the Diagnosis

• Before starting treatment, confirm hypertension using out-of-office measurements rather than relying solely on office readings 1, 2
• Use home blood pressure monitoring (threshold ≥135/85 mmHg) or 24-hour ambulatory monitoring (threshold ≥130/80 mmHg) 3, 1
• At the first visit, measure blood pressure in both arms simultaneously and use the arm with higher readings for subsequent measurements 3

Lifestyle Modifications (Foundation for All Patients)

• Dietary changes: Follow a DASH eating pattern with 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products 1, 2
• Sodium restriction: Limit intake to <2,300 mg/day, ideally <1,500 mg/day 1, 4
• Potassium supplementation: Increase intake through dietary sources 1, 2
• Weight management: Achieve caloric restriction if BMI ≥25 kg/m² 1, 2
• Physical activity: Engage in at least 150 minutes of moderate-intensity aerobic exercise per week 1, 2
• Alcohol moderation: Limit to ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• Smoking cessation: Recommend for all patients 1, 2

Pharmacologic Therapy: When to Start

Immediate Initiation (High-Risk Patients)

• Start medications immediately alongside lifestyle modifications if the patient has: 1, 4, 2
  • Established cardiovascular disease
  • Chronic kidney disease
  • Diabetes mellitus
  • Target organ damage
  • 10-year ASCVD risk ≥10%

Delayed Initiation (Low-to-Moderate Risk)

• Critical guideline divergence: The 2020 International Society of Hypertension recommends waiting 3-6 months of lifestyle intervention before starting medications in low-risk patients with Grade 1 hypertension (140-159/90-99 mmHg) 3
• However, the 2024 European Society of Cardiology guidelines supersede this, recommending simultaneous lifestyle advice AND medication for all patients with office BP ≥140/90 mmHg 1
• Given the stronger evidence for earlier intervention and improved cardiovascular outcomes, do not delay pharmacotherapy for a trial of lifestyle modification alone 1

First-Line Pharmacologic Agents

Non-Black Patients

• Monotherapy for BP 130-150/80-90 mmHg: Start with a single agent 1, 2

  • ACE inhibitor (e.g., lisinopril 10 mg daily) 3, 5
  • ARB (e.g., losartan 50 mg daily) 3, 6
  • Thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) 1, 7
  • Dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily) 3, 7

• Dual therapy for BP ≥150/90 mmHg: Start with two agents simultaneously, preferably as a single-pill combination 1, 2

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

Black Patients

• Initial therapy should include: 3, 1, 2
  • ARB + dihydropyridine calcium channel blocker, OR
  • Calcium channel blocker + thiazide/thiazide-like diuretic
• Avoid ACE inhibitors as monotherapy due to reduced response in this population 1, 2

Special Population Considerations

• Chronic kidney disease or albuminuria (UACR ≥30 mg/g): Start with ACE inhibitor or ARB to reduce progressive kidney disease risk 1, 4
• Coronary artery disease: Use ACE inhibitor or ARB as first-line; add beta-blocker if history of myocardial infarction, active angina, or heart failure with reduced ejection fraction 1, 2
• Heart failure: Beta-blockers are indicated in addition to other agents 1
• Pregnancy or planning pregnancy: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors are absolutely contraindicated due to fetal injury and death risk 1, 2

Blood Pressure Targets

• Most adults <65 years: <130/80 mmHg 1, 2, 7
• Adults ≥65 years: Systolic <130 mmHg if well-tolerated 1, 2
• Patients with diabetes, CKD, or established CVD: <130/80 mmHg 1, 2
• European guidelines recommend: Systolic 120-129 mmHg for most adults when treatment is well tolerated 1

Titration Strategy

• If starting with monotherapy: Increase to full dose of initial agent before adding a second drug 3, 1
  • Lisinopril: Titrate from 10 mg to 20-40 mg daily 1, 5
  • Losartan: Increase from 50 mg to 100 mg daily 6
• If BP not controlled with two drugs: Add a third agent from a different class (typically the missing component of ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1
• Resistant hypertension (uncontrolled on three drugs): Add low-dose spironolactone 25 mg daily 1

Monitoring and Follow-Up

• Recheck blood pressure in 1 month after initiating or adjusting therapy 2
• Achieve BP control within 3 months 3, 1
• 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 2

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with BP ≥140/90 mmHg—current evidence favors simultaneous initiation 1
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available, as longer-acting thiazide-like diuretics have superior cardiovascular outcome data 1, 7
• Do not use beta-blockers as initial therapy unless a specific indication exists (heart failure, coronary disease, post-MI) 1
• Avoid ACE inhibitors in patients with history of angioedema or severe bilateral renal artery stenosis 2
• Do not use thiazides in patients with active gout unless on uric acid-lowering therapy 1