What is the recommended treatment for hypertension?

How to Treat Hypertension

Start immediately with dual combination therapy using a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, prescribed as a single-pill combination whenever possible, targeting systolic blood pressure of 120-129 mmHg for most adults under 65 years if tolerated. 1, 2, 3

Initial Pharmacological Treatment Algorithm

Step 1: Two-Drug Combination (First-Line)

• Prescribe a RAS blocker (ACE inhibitor like lisinopril or ARB like losartan) combined with EITHER a dihydropyridine calcium channel blocker (such as amlodipine) OR a thiazide/thiazide-like diuretic (such as chlorthalidone or hydrochlorothiazide) 1, 2, 3
• Always use single-pill fixed-dose combinations when available—this significantly improves adherence and is no longer optional 2, 3
• For Black patients specifically, initiate with a thiazide-like diuretic plus calcium channel blocker, or calcium channel blocker plus ARB 2, 3

Step 2: Three-Drug Combination (If BP Uncontrolled After 4 Weeks)

• Escalate to triple therapy: RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, again preferably as a single-pill combination 2, 3

Step 3: Four-Drug Combination (Resistant Hypertension)

• Add a mineralocorticoid receptor antagonist (spironolactone) as the fourth agent 2

Blood Pressure Targets by Population

Standard Adults (<65 years)

• Target systolic BP 120-129 mmHg and diastolic BP <80 mmHg if well tolerated 1, 2, 3

Older Adults (≥65 years)

• Target systolic BP 130-139 mmHg 2, 3

High-Risk Patients (Diabetes, CKD, Established CVD)

• Target <130/80 mmHg 4, 2, 3

Patients with Heart Failure

• Target <130/80 mmHg but maintain >120/70 mmHg 4, 2

Patients with Previous Stroke/TIA

• Target systolic BP 120-130 mmHg 2, 3

Special Population Modifications

Coronary Artery Disease

• Use RAS blockers and beta-blockers as first-line agents (irrespective of BP levels), with or without calcium channel blockers 4, 2
• Target <130/80 mmHg 4, 2
• Add lipid-lowering therapy targeting LDL-C <55 mg/dL (1.4 mmol/L) 4
• Prescribe antiplatelet therapy with aspirin 4

Heart Failure with Reduced Ejection Fraction (HFrEF)

• Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists as first-line therapy 4, 2
• Consider angiotensin receptor-neprilysin inhibitor (sacubitril-valsartan) as alternative to ACE inhibitor/ARB 4
• Calcium channel blockers only if BP remains poorly controlled 4

Chronic Kidney Disease with Albuminuria/Proteinuria

• Must include a RAS blocker due to superior albuminuria reduction beyond BP lowering alone 1, 2, 3
• Target systolic BP 120-129 mmHg if eGFR >30 mL/min/1.73m² and tolerated 3

Diabetes Mellitus

• Initiate treatment at BP ≥140/90 mmHg 4, 2, 3
• Target <130/80 mmHg 4, 2, 3
• Use RAS inhibitor combined with calcium channel blocker and/or thiazide-like diuretic 2

Previous Stroke (Ischemic)

• Use RAS blockers, calcium channel blockers, and diuretics as first-line agents 4, 2, 3
• Add lipid-lowering therapy targeting LDL-C <70 mg/dL (1.8 mmol/L) 4
• Prescribe antiplatelet therapy 4

Previous Stroke (Hemorrhagic)

• Use RAS blockers, calcium channel blockers, and diuretics as first-line agents 4
• Do NOT routinely prescribe antiplatelet therapy 4

Essential Lifestyle Modifications (For All Patients)

Weight Management

• Reduce to target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 2, 3

Dietary Modifications

• Restrict sodium to <2,300 mg/day 1, 2, 3
• Consume 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 1, 2
• Eliminate sugar-sweetened beverages and restrict free sugar to maximum 10% of energy intake 1

Physical Activity

• Minimum 150 minutes/week of moderate-intensity aerobic activity OR 75 minutes/week of vigorous activity 2, 3
• Add resistance training 2-3 times weekly 2

Alcohol and Tobacco

• Limit alcohol to ≤2 drinks/day for men and ≤1 drink/day for women 1, 2, 3
• Complete tobacco cessation with referral to smoking cessation programs 1, 2

The evidence supporting lifestyle modifications is robust—a comprehensive intervention combining weight loss, DASH diet, sodium restriction, and exercise can reduce systolic BP by 9.5-12.1 mmHg even in patients already on antihypertensive medication 5. These effects are partially additive and enhance pharmacologic therapy efficacy 6.

Critical Pitfalls to Avoid

Never combine two RAS blockers (ACE inhibitor + ARB) together—this increases adverse effects without additional benefit 2, 3

Do not start with monotherapy and delay combination therapy—this outdated approach delays BP control and increases cardiovascular risk 2

Do not prescribe multiple separate pills when single-pill combinations are available—this significantly reduces adherence and treatment success 2, 3

Do not use beta-blockers as first-line therapy except in specific conditions (CAD, heart failure, post-MI)—they are less effective for primary hypertension 2

Monitoring and Follow-Up Strategy

• Achieve target BP within 3 months of treatment initiation 1, 2, 3
• Use both office and home BP readings for regular monitoring 2
• Monitor renal function and potassium at least annually when using ACE inhibitor, ARB, or diuretic 1, 2
• Continue lifelong BP-lowering treatment if well tolerated, even beyond age 85 2, 3
• Employ multidisciplinary team approaches involving pharmacists to enhance adherence 4, 2

Adjunctive Cardiovascular Risk Reduction

Aspirin for Primary Prevention

• Use 75 mg daily if patient is ≥50 years with BP controlled to <150/90 mmHg AND has target organ damage, diabetes, or 10-year CVD risk ≥20% 4

Statin Therapy

• Prescribe for all patients with hypertension complicated by established CVD, regardless of baseline cholesterol 4
• For primary prevention, use in patients with 10-year CVD risk ≥20% and total cholesterol ≥3.5 mmol/L 4

The most recent high-quality guidelines (2020-2025) consistently emphasize immediate dual combination therapy over the outdated "start low, go slow" monotherapy approach 1, 2, 3. This paradigm shift is based on evidence showing faster BP control, better adherence with single-pill combinations, and improved cardiovascular outcomes. The 2004 British Hypertension Society guidelines 4 represent older practice patterns that have been superseded by current evidence favoring more aggressive initial combination therapy.