What is the recommended initial treatment approach for a patient diagnosed with hypertension?

Hypertension Smart Phrase

Assessment & Diagnosis

• Confirm hypertension with out-of-office measurements (home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg) before initiating treatment 1, 2
• Calculate 10-year ASCVD risk score to guide treatment intensity 2
• Check for target organ damage: obtain baseline creatinine, potassium, urinalysis for albuminuria, ECG 1
• Screen for secondary causes if indicated: young age (<30 years), resistant hypertension, or sudden onset 1

Blood Pressure Classification & Treatment Thresholds

• Stage 1 (130-139/80-89 mmHg): Initiate lifestyle modifications; add single pharmacologic agent if ASCVD risk ≥10%, diabetes, CKD, or established CVD 2
• Stage 2 (≥140/90 mmHg): Initiate both lifestyle modifications AND pharmacologic therapy simultaneously with two-drug combination, preferably as single-pill combination 1, 2
• Severe elevation (≥150/90 mmHg or ≥160/100 mmHg): Start two antihypertensive agents immediately from different classes 1, 2

Lifestyle Modifications (Initiate for ALL patients with BP >120/80 mmHg)

• Dietary interventions: DASH or Mediterranean eating pattern with 8-10 servings/day fruits and vegetables, 2-3 servings/day low-fat dairy 1, 2
• Sodium restriction: Target <2,300 mg/day (ideally <1,500 mg/day) 1, 2
• Potassium supplementation: Increase dietary potassium through food sources 1, 2
• Weight reduction: Achieve BMI <25 kg/m² through caloric restriction if overweight 1, 2
• Physical activity: ≥150 minutes/week moderate-intensity aerobic exercise 1, 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• Smoking cessation: Mandatory for all patients 1, 2

First-Line Pharmacologic Therapy

For Stage 1 Hypertension (130-139/80-89 mmHg) with High Risk

• Start with single agent from first-line options: ACE inhibitor (lisinopril 10 mg daily), ARB (losartan 50 mg daily), thiazide-like diuretic (chlorthalidone 12.5-25 mg daily), or dihydropyridine calcium channel blocker (amlodipine 5 mg daily) 1, 2, 3, 4
• Titrate to full dose before adding second agent: Lisinopril can be increased to 20-40 mg daily; losartan to 100 mg daily 1, 3, 4

For Stage 2 Hypertension (≥140/90 mmHg)

• Start with two-drug combination immediately: RAS blocker (ACE inhibitor or ARB) PLUS either dihydropyridine calcium channel blocker OR thiazide-like diuretic 1, 2
• Preferred combinations:
  • Lisinopril 10 mg + chlorthalidone 12.5-25 mg daily 1
  • Lisinopril 10 mg + amlodipine 5 mg daily 1
  • Losartan 50 mg + chlorthalidone 12.5-25 mg daily 1, 4
• Use single-pill combinations when available to improve adherence 1, 2

Special Population Considerations

Black Patients

• Initial therapy: ARB + dihydropyridine calcium channel blocker OR calcium channel blocker + thiazide-like diuretic (avoid ACE inhibitor monotherapy due to reduced response) 1, 2

Diabetes or Chronic Kidney Disease (CKD) or Albuminuria (UACR ≥30 mg/g)

• First-line agent must be ACE inhibitor or ARB to reduce progressive kidney disease risk 1, 2

Coronary Artery Disease

• First-line agent must be ACE inhibitor or ARB 1
• 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 ACE inhibitor/ARB 1

Pregnancy or Planning Pregnancy

• Absolute contraindications: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors (use methyldopa or calcium channel blockers instead) 1, 2

Hepatic Impairment

• Start losartan at 25 mg daily (not studied in severe hepatic impairment) 4

Pediatric Patients (≥6 years)

• Lisinopril starting dose: 0.07 mg/kg once daily (up to 5 mg total), maximum 0.61 mg/kg (up to 40 mg) once daily 3
• Losartan starting dose: 0.7 mg/kg once daily (up to 50 mg total), maximum 1.4 mg/kg (up to 100 mg) once daily 4

Blood Pressure Targets

• Adults <65 years: <130/80 mmHg 1, 2
• Adults ≥65 years: Systolic <130 mmHg (if well-tolerated) 1, 2
• Optimal target for most adults: Systolic 120-129 mmHg when treatment is well-tolerated 1

Titration Strategy for Resistant Hypertension

• Step 1: Optimize to full dose of initial agent(s) before adding additional medications 1
• Step 2: If not controlled on two drugs, escalate to three-drug combination (ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic) 1
• Step 3: If 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 when spironolactone contraindicated or not tolerated 1

Monitoring & Follow-Up

• Recheck BP in 1 month after initiating or adjusting therapy 1, 2
• Check creatinine and potassium 7-14 days after starting or adjusting ACE inhibitors, ARBs, or diuretics 1, 2
• Monitor for hyperkalemia with ACE inhibitors/ARBs 2
• Monitor for hypokalemia with thiazide diuretics 1
• Achieve BP control within 3 months, with follow-up every 1-3 months until controlled 1

Common Pitfalls to Avoid

• Do NOT delay pharmacotherapy for lifestyle modification trial in patients with BP ≥140/90 mmHg—start both simultaneously 1
• Avoid hydrochlorothiazide when chlorthalidone or indapamide are available (longer-acting thiazide-like diuretics preferred) 1
• Avoid beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease, post-MI) 1
• Avoid ACE inhibitors in patients with history of angioedema 1
• Avoid ACE inhibitors/ARBs in severe bilateral renal artery stenosis (risk of acute renal failure) 1
• Use thiazides cautiously in patients with gout unless on uric acid-lowering therapy 1