What is the first line medication for a male adult patient with hypertension, without underlying medical conditions or complications?

First-Line Medication for Male Hypertension

For a male adult with uncomplicated hypertension, initiate treatment with a thiazide or thiazide-like diuretic (preferably chlorthalidone), an ACE inhibitor/ARB, or a long-acting calcium channel blocker—with thiazide diuretics showing the strongest evidence for preventing heart failure and stroke. 1, 2

Primary Drug Class Options

All four major drug classes are acceptable as first-line therapy based on high-quality evidence 2, 3:

• Thiazide/thiazide-like diuretics (chlorthalidone, hydrochlorothiazide)
• ACE inhibitors (lisinopril, enalapril) or ARBs (candesartan, losartan)
• Long-acting dihydropyridine calcium channel blockers (amlodipine)

Why Thiazide Diuretics May Be Optimal

Chlorthalidone specifically demonstrates superior outcomes in head-to-head trials 1:

• More effective than ACE inhibitors (lisinopril) in preventing stroke 1
• Superior to calcium channel blockers (amlodipine) in preventing heart failure 1
• Reduces all-cause mortality by 2-3 deaths per 100 patients treated over 4-5 years 4

The 2017 ACC/AHA guidelines note that meta-analyses and the largest individual RCT (ALLHAT) suggest thiazide diuretics, especially chlorthalidone, provide optimal first-step therapy 1.

Treatment Initiation Strategy

Stage 1 Hypertension (130-139/80-89 mmHg)

• Start with single-agent monotherapy 1, 2
• Titrate dosage upward as needed 1
• Add sequential agents from different classes if target not achieved 1

Stage 2 Hypertension (≥140/90 mmHg or >20/10 mmHg above goal)

• Initiate with two-drug combination therapy from different first-line classes 1, 2, 3
• Preferably use single-pill combination products to improve adherence 3
• Typical effective combinations: diuretic + ACE inhibitor/ARB + calcium channel blocker 2

Blood Pressure Targets

Target <130/80 mmHg for most adult males 2:

• <130/80 mmHg for adults with known CVD or 10-year ASCVD risk ≥10% (Class I recommendation) 1
• <130/80 mmHg may be reasonable for those without elevated CVD risk (Class IIb) 1
• <140/90 mmHg is acceptable for patients without comorbidities 2, 3

Critical Considerations

Drugs to Avoid as First-Line

• Beta-blockers are NOT recommended as first-line unless the patient has ischemic heart disease or heart failure 1, 3
• Alpha-blockers are less effective than thiazide diuretics for CVD prevention 1
• Never combine ACE inhibitors with ARBs—this increases adverse effects without additional benefit 3

Common Pitfalls

• Beta-blockers were significantly less effective than diuretics for stroke prevention (30% lower risk with diuretics) 1
• ACE inhibitors alone are less effective than thiazides or CCBs in lowering BP and preventing stroke 1
• Nondihydropyridine CCBs (verapamil, diltiazem) should be avoided in heart failure with reduced ejection fraction 1

Monitoring Schedule

• Monthly follow-up after initiating or changing medications until target BP achieved 2, 3
• Every 3-5 months once blood pressure is controlled 2, 3
• Monitor renal function and potassium within first 3 months for patients on ACE inhibitors, ARBs, or diuretics 2

Most Patients Require Multiple Agents

Recognize that most adults with hypertension require >1 drug to control BP 1. The evidence strongly supports early combination therapy for stage 2 hypertension rather than sequential monotherapy titration 1, 3.