What is the initial treatment for hypertension?

Initial Treatment for Hypertension

Begin with simultaneous lifestyle modifications and pharmacological therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg), starting with a single first-line agent (ACE inhibitor, ARB, thiazide-like diuretic, or calcium channel blocker) if BP is 130-150/80-90 mmHg, or two agents from different classes if BP is ≥150/90 mmHg. 1, 2

Confirming the Diagnosis

Before initiating treatment, confirm hypertension using out-of-office measurements rather than relying solely on office readings 1, 2:

• Home BP monitoring threshold: ≥135/85 mmHg 3, 1
• 24-hour ambulatory BP monitoring threshold: ≥130/80 mmHg 3, 1

Lifestyle Modifications (Start Immediately for All Patients)

Implement these evidence-based interventions, which reduce BP and enhance medication efficacy 4:

Dietary Changes:

• Follow a DASH eating pattern with 8-10 servings/day of fruits and vegetables 1, 2
• Consume 2-3 servings/day of low-fat dairy products 1, 2
• Restrict sodium to <2,300 mg/day (ideally <1,500 mg/day) 1, 5, 2
• Increase dietary potassium intake through fruits and vegetables 1, 2

Weight and Physical Activity:

• Achieve weight loss if BMI ≥25 kg/m² through caloric restriction 1, 2
• Engage in at least 150 minutes of moderate-intensity aerobic exercise per week 1, 2

Substance Use:

• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• Complete smoking cessation 1, 2

Pharmacological Therapy: When to Start

Immediate pharmacotherapy is indicated for: 1, 5, 2

• High-risk patients with established CVD, chronic kidney disease, diabetes, or target organ damage 3, 1
• Patients aged 50-80 years with hypertension 3
• Stage 1 hypertension with 10-year ASCVD risk ≥10% 1

For low-to-moderate risk patients: The 2024 ESC guidelines recommend starting both lifestyle advice AND BP-lowering medication simultaneously for office BP ≥140/90 mmHg, rather than delaying pharmacotherapy for 3-6 months of lifestyle modification alone 1

First-Line Pharmacological Agents

For Non-Black Patients:

If BP 130-150/80-90 mmHg, start with monotherapy: 3, 1, 2

• Low-dose ACE inhibitor (e.g., lisinopril 10 mg daily) 6 OR
• Low-dose ARB (e.g., losartan 50 mg daily) 7 OR
• Thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) 1 OR
• Dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily) 2

If BP ≥150/90 mmHg, start with two agents simultaneously: 1, 2

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker, OR
• RAS blocker + thiazide/thiazide-like diuretic
• Preferably as a single-pill combination to improve adherence 1, 2

For Black Patients:

Black patients have reduced response to ACE inhibitors as monotherapy 1, 2:

• Start with ARB + dihydropyridine calcium channel blocker, OR
• Calcium channel blocker + thiazide/thiazide-like diuretic 3, 1, 5

Special Population Considerations:

Diabetes or chronic kidney disease with albuminuria (UACR ≥30 mg/g):

• Use ACE inhibitor or ARB as first-line therapy to reduce progressive kidney disease 1, 5, 2

Coronary artery disease:

• Use ACE inhibitor or ARB as first-line therapy 1, 2
• Add beta-blocker if history of MI, active angina, or heart failure with reduced ejection fraction 2

Heart failure:

• Beta-blockers are indicated in addition to other agents 1

Pregnancy or women planning pregnancy:

• ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors are absolutely contraindicated due to fetal injury and death 1, 2
• Use calcium channel blockers or methyldopa instead 2

Elderly (>80 years) or frail patients:

• Consider monotherapy with lower starting doses 3

Titration Strategy

If starting with monotherapy: 1, 2

1. Increase to full dose of initial agent before adding a second drug (e.g., lisinopril 10 mg → 20-40 mg daily) 1, 6
2. If BP remains uncontrolled, add a dihydropyridine calcium channel blocker 1
3. If still uncontrolled, add a thiazide/thiazide-like diuretic to create a three-drug combination 1
4. If BP remains uncontrolled on three drugs, add spironolactone 25 mg daily 1

If starting with two agents:

• Increase to full doses before adding a third agent 1

Blood Pressure Targets

For most adults <65 years: 1, 2, 4

• Target: <130/80 mmHg

For adults ≥65 years: 1, 2

• Target: Systolic <130 mmHg if well-tolerated
• Individualize based on frailty 3, 1

For patients with diabetes, CKD, or established CVD: 1, 2

• Target: <130/80 mmHg

Monitoring and Follow-Up

Initial follow-up: 1, 2

• Recheck BP in 1 month after initiating therapy
• Achieve BP control within 3 months 3, 1

Laboratory monitoring: 1, 5, 2

• Check serum creatinine and potassium 7-14 days after starting or adjusting doses of ACE inhibitors, ARBs, or diuretics
• Watch for hyperkalemia with ACE inhibitors/ARBs 2
• Watch for hypokalemia with diuretics 1, 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—longer-acting thiazide-like diuretics have superior cardiovascular outcome data 1, 2
• 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 2
• Avoid ACE inhibitors/ARBs in severe bilateral renal artery stenosis due to acute renal failure risk 2
• Use thiazides cautiously in patients with gout unless on uric acid-lowering therapy 2