What dose of antihypertensive medication should I start someone with hypertension (blood pressure of 156/96 mmHg) on?

Starting Dose for Hypertension with BP 156/96 mmHg

For a patient with blood pressure 156/96 mmHg (Grade 2 hypertension), you should initiate combination therapy with two antihypertensive agents rather than monotherapy, using a fixed-dose single-pill combination of an ACE inhibitor or ARB plus either a calcium channel blocker or thiazide diuretic. 1

Rationale for Combination Therapy

• The 2024 ESC guidelines explicitly recommend combination BP-lowering treatment as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg), as trial evidence demonstrates more effective BP control versus monotherapy 1
• Preferred combinations are a RAS blocker (either an ACE inhibitor or ARB) with a dihydropyridine calcium channel blocker or diuretic 1
• Fixed-dose single-pill combinations are strongly recommended over separate pills to improve adherence and persistence with treatment 1

Specific Starting Dose Recommendations

Option 1: ACE Inhibitor + Calcium Channel Blocker

• Lisinopril 10 mg + Amlodipine 5 mg once daily 2, 1
• The FDA label specifies lisinopril 10 mg as the recommended initial dose for hypertension in adults 2
• Amlodipine 5 mg is the most appropriate starting dose, with adjustment to 10 mg if necessary after 6 weeks 3, 4

Option 2: ACE Inhibitor + Thiazide Diuretic

• Lisinopril 10 mg + Hydrochlorothiazide 12.5 mg once daily 2, 1
• If using this combination, the FDA label recommends starting lisinopril at 5 mg when combined with a diuretic 2

Option 3: ARB + Calcium Channel Blocker

• ARB (e.g., candesartan or olmesartan) + Amlodipine 5 mg once daily 1, 5

Blood Pressure Targets

• Target systolic BP of 120-129 mmHg in most adults, provided treatment is well tolerated 1
• Minimum acceptable target is <140/90 mmHg 1
• If the 120-129 mmHg target is poorly tolerated, apply the ALARA principle (as low as reasonably achievable) 1

Monitoring and Follow-up

• Reassess blood pressure within 2-4 weeks after initiating therapy 6
• Goal is to achieve target BP within 3 months of initiating treatment 6
• If BP remains uncontrolled on two-drug combination, increase to three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic), preferably in a single-pill combination 1

Critical Pitfalls to Avoid

• Do not start with monotherapy for BP 156/96 mmHg, as this represents Grade 2 hypertension requiring prompt dual therapy 1
• Do not combine two RAS blockers (ACE inhibitor + ARB), as this increases adverse events without additional benefit 1
• Do not delay treatment intensification—prompt pharmacological intervention is required alongside lifestyle measures for confirmed BP ≥140/90 mmHg 1
• Medications should be taken at the most convenient time of day for the patient to establish a habitual pattern and improve adherence 1

Lifestyle Modifications (Concurrent with Pharmacotherapy)

• Adopt Mediterranean or DASH diet 1
• Restrict sodium to <2 g/day (provides additive BP reduction of 10-20 mmHg) 6
• Limit alcohol to <100 g/week of pure alcohol 1
• Stop tobacco smoking with supportive care 1
• Restrict free sugar consumption to maximum 10% of energy intake 1