What is the recommended treatment for hypertension?

Hypertension Treatment

For most adults with confirmed hypertension, immediately initiate combination therapy with two first-line agents—specifically a RAS blocker (ACE inhibitor or ARB) combined with either a calcium channel blocker or thiazide/thiazide-like diuretic—preferably as a single-pill combination to improve adherence and achieve target blood pressure. 1

Blood Pressure Targets

The target blood pressure varies by age and comorbidities:

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

These targets prioritize reduction in cardiovascular morbidity and mortality, with evidence showing that a 10 mmHg systolic BP reduction decreases cardiovascular events by approximately 20-30% 4.

Pharmacological Treatment Algorithm

Step 1: Initial Dual Therapy

Start with a two-drug combination at low doses, preferably as a single-pill fixed-dose combination 1, 2:

• RAS blocker (ACE inhibitor like lisinopril 5 or ARB like losartan 6)
• PLUS either a dihydropyridine calcium channel blocker (e.g., amlodipine) or thiazide/thiazide-like diuretic (e.g., chlorthalidone) 1, 2

Step 2: Triple Therapy

If BP remains uncontrolled after 3 months, escalate to a three-drug combination 2:

• RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic 2

Step 3: Resistant Hypertension

Add a mineralocorticoid receptor antagonist (spironolactone) as the fourth agent 1, 3

Special Population Considerations

Black Patients

Initial therapy should include a thiazide-like diuretic plus calcium channel blocker, or calcium channel blocker plus ARB 1, 3. Note that losartan's stroke reduction benefit in patients with left ventricular hypertrophy does not apply to Black patients 6.

Patients with Coronary Artery Disease

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

Patients with Heart Failure

• Target BP <130/80 mmHg but >120/70 mmHg 1, 3
• Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1, 3

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 Chronic Kidney Disease

• Include a RAS blocker when albuminuria/proteinuria is present due to superior albuminuria reduction 1, 2, 3
• Losartan specifically reduces progression of diabetic nephropathy in type 2 diabetics with elevated creatinine and proteinuria 6

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 1, 3

Lifestyle Modifications

All patients should implement comprehensive lifestyle changes, which have additive BP-lowering effects with pharmacotherapy 4:

• Weight reduction: Target BMI 20-25 kg/m² and waist circumference <94 cm for men or <80 cm for women 1, 2
• Sodium restriction: <2,300 mg/day 1, 2
• Dietary pattern: 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 1, 2
• 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 1
• Alcohol limitation: ≤2 drinks/day for men and ≤1 drink/day for women 1, 2
• Complete tobacco cessation with referral to smoking cessation programs 1, 2

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB) due to increased adverse effects without additional benefit 1
• Do not delay initiation of combination therapy in favor of monotherapy—this outdated approach delays BP control 1
• Avoid prescribing multiple separate pills when single-pill combinations are available, as this significantly reduces adherence 1
• 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 1, 2, 3
• Use both office and home BP readings for regular monitoring 1
• 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 1
• Employ multidisciplinary team approaches involving pharmacists to enhance adherence 1