What is the initial management approach for a patient with hypertension?

Initial Management of Hypertension

For patients with confirmed hypertension (BP ≥140/90 mmHg), initiate both lifestyle modifications and pharmacological therapy simultaneously with a two-drug combination, preferably as a single-pill combination of a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic. 1, 2, 3

Confirming the Diagnosis

Before starting treatment, confirm hypertension using out-of-office measurements rather than relying solely on clinic readings 1, 3:

• Home BP monitoring threshold: ≥135/85 mmHg 1, 3
• 24-hour ambulatory BP monitoring threshold: ≥130/80 mmHg 1, 3
• Measure BP in both arms at the first visit and use the arm with higher readings for subsequent measurements 3
• Use a validated automated upper arm cuff device with appropriate cuff size 3

Lifestyle Modifications (Start Immediately)

Implement these evidence-based interventions alongside medications, as they enhance drug efficacy 2, 4:

• Weight loss: For overweight patients through caloric restriction 2
• DASH diet pattern: Emphasize 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products 2, 5, 6
• Sodium restriction: <2,300 mg/day 2
• Potassium supplementation: Through dietary sources (fruits and vegetables) 2, 7
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 2
• Smoking cessation: For all patients 2

Initial Pharmacological Therapy

Standard Two-Drug Combination (Most Patients)

Start with one of these combinations 1, 2, 3:

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

Specific dosing examples:

• Lisinopril 10 mg + amlodipine 5 mg daily 2, 8
• Losartan 50 mg + amlodipine 5 mg daily 2, 9
• Lisinopril 10 mg + chlorthalidone 12.5-25 mg daily 2, 8

Key point: Chlorthalidone is preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcome data 2, 4

Race-Specific Considerations

For Black patients, use 2, 3:

• ARB + dihydropyridine calcium channel blocker, OR
• Calcium channel blocker + thiazide/thiazide-like diuretic

This recommendation exists because Black patients show reduced response to ACE inhibitors as monotherapy 2

Single-Drug Initiation (Selected Cases Only)

For patients with BP between 130/80 mmHg and 150/90 mmHg, single-agent therapy may be considered 2:

• Start with lisinopril 10 mg daily or losartan 50 mg daily 2, 8, 9
• However, the 2024 ESC guidelines favor two-drug initiation even at these levels 1, 2

Blood Pressure Targets

• Adults <65 years: <130/80 mmHg 2, 3, 4
• Adults 65-85 years: Systolic BP 120-129 mmHg if well tolerated 1, 2, 3
• Patients with diabetes, CKD, or established CVD: <130/80 mmHg 2, 3

Special Population Considerations

Chronic Kidney Disease or Diabetes

• Include an ACE inhibitor or ARB as part of initial therapy 2, 3
• For patients with albuminuria (UACR ≥30 mg/g), ACE inhibitor or ARB reduces risk of progressive kidney disease 2

Heart Failure

• Include ACE inhibitor or ARB, beta-blocker, and mineralocorticoid receptor antagonist in the regimen 2, 3

Coronary Artery Disease

• ACE inhibitors or ARBs are recommended as first-line therapy 2

Pregnancy or Women Planning Pregnancy

• Absolutely contraindicated: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors 2, 3
• Use calcium channel blockers or methyldopa instead 2

Patients with Hepatic Impairment

• Start losartan at 25 mg once daily for mild-to-moderate hepatic impairment 9

Patients on Diuretics or Volume Depleted

• Start with lower dose: lisinopril 5 mg or losartan 25 mg daily 8, 9

Monitoring and Titration Strategy

Initial Follow-Up

• Recheck BP in 1 month after initiating therapy 2
• Check serum creatinine and potassium 7-14 days after starting or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2, 3
• Monitor for hypokalemia when using diuretics 2

Escalation Algorithm if BP Not Controlled

Step 1: If BP not controlled with two drugs, optimize to full doses before adding third agent 2

• Lisinopril can be titrated from 10 mg to 20-40 mg daily 2, 8
• Losartan can be increased from 50 mg to 100 mg daily 2, 9

Step 2: Add a third drug from a different class to create the standard three-drug combination 2:

• ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic

Step 3: For resistant hypertension (BP not controlled on three drugs), add spironolactone 25 mg daily 1, 2

Step 4: Beta-blockers and alpha-blockers are fourth- or fifth-line agents used when spironolactone is not tolerated or contraindicated 2

Timeline for BP Control

• Achieve target BP within 3 months 2, 3
• Follow-up every 1-3 months until BP is controlled 2

Common Pitfalls to Avoid

• Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with BP ≥140/90 mmHg 2
• Avoid using hydrochlorothiazide when chlorthalidone or indapamide are available 2
• Do not use beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease) 2
• Do not use ACE inhibitors/ARBs in patients with severe bilateral renal artery stenosis due to acute renal failure risk 2
• Use thiazides cautiously in patients with gout or history of acute gout 2
• Avoid ACE inhibitors in patients with history of angioedema 2
• Do not ignore poor compliance as a cause of resistant hypertension—consider simplifying regimen or supervised administration 1
• Screen for secondary causes in resistant hypertension, including obstructive sleep apnea, renal artery stenosis, hyperaldosteronism, and volume overload 1
• Rule out white coat hypertension and pseudohypertension (in elderly with stiff arteries) using ambulatory BP monitoring 1

Evidence Supporting Early Combination Therapy

The shift toward immediate two-drug combination therapy is based on evidence showing 1, 2:

• Faster achievement of BP control
• Improved medication adherence with single-pill combinations
• More rapid reduction in cardiovascular risk
• Greater likelihood of reaching target BP compared to sequential monotherapy

A 10 mmHg reduction in systolic BP decreases cardiovascular events by approximately 20-30% 4