What are the initial treatment recommendations for a patient with hypertension, including lifestyle modifications and medication options?

Initial Treatment for Hypertension

For patients with confirmed hypertension ≥140/90 mmHg, initiate lifestyle modifications immediately; for blood pressure ≥140/90 mmHg, add prompt pharmacologic therapy with a single drug if BP is 140-159/90-99 mmHg, or start two drugs (or a single-pill combination) if BP is ≥160/100 mmHg. 1, 2

Blood Pressure Classification and Treatment Thresholds

• Stage 1 Hypertension (140-159/90-99 mmHg): Begin with lifestyle modifications plus a single antihypertensive medication 1, 2
• Stage 2 Hypertension (≥160/100 mmHg): Initiate lifestyle modifications plus two antihypertensive medications simultaneously (or a single-pill combination) to achieve more rapid blood pressure control 1, 2
• Blood pressure 120-139/80-89 mmHg: Lifestyle modifications alone for 3-6 months; if BP remains uncontrolled, then start medication 3

Lifestyle Modifications (Essential for All Patients)

All patients with blood pressure >120/80 mmHg should implement comprehensive lifestyle changes, which can lower BP by 10-20 mmHg and enhance medication effectiveness. 1, 4

Dietary Interventions

• DASH diet pattern: 8-10 servings of fruits and vegetables daily, 2-3 servings of low-fat dairy products daily, reduced saturated and trans fats 1, 3
• Sodium restriction: Limit intake to <2,300 mg/day (ideally <1,500 mg/day for optimal effect) 1, 4
• Potassium supplementation: Increase dietary potassium intake through food sources 1, 4
• Alcohol moderation: Maximum 2 drinks/day for men, 1 drink/day for women 1, 4

Weight and Physical Activity

• Weight reduction: Achieve and maintain healthy body mass index (BMI 20-25 kg/m²) through caloric restriction if overweight 1, 4
• Regular physical activity: Engage in consistent aerobic exercise 1, 4

First-Line Pharmacologic Therapy

For Non-Black Patients

Start with an ACE inhibitor or ARB as first-line monotherapy for BP 140-159/90-99 mmHg. 2, 5

• ACE inhibitors: Lisinopril, enalapril 2, 5, 4
• ARBs: Losartan 50 mg once daily (can increase to 100 mg), candesartan 6, 4
• Alternative first-line options: Thiazide-like diuretics (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide) or dihydropyridine calcium channel blockers (amlodipine 5-10 mg daily) 1, 2, 4

For Black Patients

Initiate therapy with a dihydropyridine calcium channel blocker (DHP-CCB) plus either an ARB or thiazide-like diuretic. 2, 7

• The combination of DHP-CCB plus thiazide diuretic is more effective than DHP-CCB plus ACE inhibitor/ARB in Black patients 2, 7

For Patients with Specific Comorbidities

• Diabetes with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB at maximum tolerated dose as first-line therapy 1
• Established coronary artery disease: ACE inhibitor or ARB recommended as first-line therapy 1
• Chronic kidney disease with albuminuria: ACE inhibitor or ARB to reduce progressive kidney disease risk 1

Initial Dual Therapy for Severe Hypertension

For BP ≥160/100 mmHg, start with two medications from different classes simultaneously to achieve faster BP control. 1, 2

Recommended Two-Drug Combinations

• ACE inhibitor or ARB + calcium channel blocker 2, 7
• ACE inhibitor or ARB + thiazide-like diuretic 2, 7
• Calcium channel blocker + thiazide-like diuretic (particularly effective in Black patients) 2, 7

Single-pill combination products improve medication adherence and should be considered 1, 5

Blood Pressure Targets

• Adults <65 years: Target <130/80 mmHg 1, 4
• Adults ≥65 years: Target SBP <130 mmHg 4
• Patients with diabetes or chronic kidney disease: Target <130/80 mmHg 1
• Initial goal for severe hypertension: Reduce BP by at least 20/10 mmHg 2
• Timeline: Achieve target BP within 3 months of initiating or modifying therapy 1, 2, 5

Monitoring and Follow-Up

• Initial follow-up: Schedule within 2-4 weeks after starting therapy to assess response and medication adherence 2, 5
• Home blood pressure monitoring: Implement to track progress and improve adherence (target <135/85 mmHg) 2, 7
• Laboratory monitoring: Check serum creatinine, estimated glomerular filtration rate, and potassium at least annually when using ACE inhibitors, ARBs, or diuretics 1

Medication Titration Algorithm

If BP remains uncontrolled on initial therapy, follow this stepwise approach:

1. On single drug therapy: Optimize dose of current medication, then add a second agent from a different class 2, 7
2. On dual therapy: Optimize doses of both medications before adding a third agent 7
3. Triple therapy: Use ACE inhibitor/ARB + calcium channel blocker + thiazide-like diuretic 2, 7
4. Resistant hypertension (uncontrolled on 3 drugs including a diuretic): Add mineralocorticoid receptor antagonist (spironolactone 25-50 mg daily) as fourth agent 1, 2, 7

Critical Contraindications and Pitfalls to Avoid

• Never combine ACE inhibitor with ARB: This increases adverse events (hyperkalemia, syncope, acute kidney injury) without additional cardiovascular benefit 1, 7
• Never combine ACE inhibitor or ARB with direct renin inhibitor (aliskiren): Particularly contraindicated in patients with diabetes 1, 8
• Avoid beta-blockers as first-line therapy: Unless compelling indications exist (prior MI, active angina, heart failure with reduced ejection fraction) 1
• Do not delay treatment intensification: Prompt action is required for Stage 2 hypertension to reduce cardiovascular risk 2, 7
• Confirm medication adherence: Non-adherence is the most common cause of apparent treatment resistance before adding additional medications 2, 7
• Screen for secondary hypertension: Particularly in patients with severe or resistant hypertension (primary aldosteronism, renal artery stenosis, obstructive sleep apnea) 2, 7

Special Considerations

• Patients with possible intravascular depletion (e.g., on diuretic therapy): Start losartan at 25 mg once daily instead of 50 mg 6
• Hepatic impairment: Start losartan at 25 mg once daily in mild-to-moderate hepatic impairment 6
• Pregnancy: ACE inhibitors and ARBs are contraindicated; aliskiren can cause fetal harm or death 8
• Bedtime dosing: Not preferentially recommended over morning dosing based on recent trial data 1