What are the initial treatment recommendations for a patient with hypertension?

Initial Treatment Recommendations for Hypertension

For newly diagnosed hypertension, initiate both lifestyle modifications and pharmacological therapy simultaneously with a two-drug combination (preferably a single-pill combination of a RAS blocker plus either a calcium channel blocker or thiazide diuretic) for most patients with confirmed BP ≥140/90 mmHg, targeting <130/80 mmHg in most adults. 1, 2

Confirming the Diagnosis

Before initiating treatment, confirm hypertension using out-of-office measurements rather than relying solely on office readings 1, 2:

• Home BP monitoring: ≥135/85 mmHg indicates hypertension 1
• 24-hour ambulatory BP monitoring: ≥130/80 mmHg confirms the diagnosis 1
• Use validated automated upper arm cuff devices with appropriate cuff size 1

Lifestyle Modifications (Initiate Immediately)

Lifestyle changes should begin at diagnosis and continue even when medications are prescribed 2, 3:

• Weight management: Achieve and maintain healthy body mass index through caloric restriction for overweight individuals 2, 4
• DASH diet pattern: Emphasize 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products 2, 4
• Sodium restriction: Limit intake to <2,300 mg/day 2, 4
• Potassium supplementation: Increase through dietary sources (fruits and vegetables) 2, 4
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise per week 2, 3
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 2, 4
• Smoking cessation: Mandatory for all patients 2, 3

Initial Pharmacological Therapy

For Non-Black Patients

Start with a two-drug combination 1, 2:

1. First-line option: Low-dose ACE inhibitor or ARB + dihydropyridine calcium channel blocker 1, 2
2. Alternative option: Low-dose ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1, 2

Specific dosing example (based on FDA labeling and guidelines):

• Lisinopril 10 mg daily + amlodipine 5 mg daily, OR 5, 2
• Lisinopril 10 mg daily + chlorthalidone 12.5-25 mg daily 5, 2

Important: Prefer chlorthalidone over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes data 2, 4

For Black Patients

Start with a two-drug combination 1, 2:

1. Preferred: Low-dose ARB + dihydropyridine calcium channel blocker 1
2. Alternative: Dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic 1

Rationale: Black patients demonstrate reduced response to ACE inhibitors as monotherapy 2, 5

Exception: Consider Monotherapy Only In

• Low-risk Grade 1 hypertension (140-159/90-99 mmHg) without cardiovascular risk factors 1
• Patients aged >80 years or frail individuals 1

Blood Pressure Targets

• Most adults <65 years: <130/80 mmHg 1, 2
• Adults ≥65 years: Systolic <130 mmHg (if well tolerated) 2, 4
• Elderly/frail patients: Individualize based on tolerability, but aim for at least <140/90 mmHg 1

Titration Strategy

Achieve BP control within 3 months using this stepwise approach 1, 2:

1. If BP not controlled on two drugs: Increase to full doses before adding third agent 1, 2

   • Example: Lisinopril can be titrated from 10 mg to 20-40 mg daily 5, 2

2. If BP still uncontrolled: Add a third drug from a different class 1

   • Standard three-drug combination: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 1, 2

3. For resistant hypertension (uncontrolled on three drugs): Add spironolactone 25 mg daily 1, 2

4. Fifth-line agents (if spironolactone contraindicated/not tolerated): amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Special Population Considerations

Patients with Comorbidities

• Coronary artery disease: ACE inhibitors or ARBs are first-line; add beta-blockers regardless of BP 1, 2
• Heart failure (HFrEF): ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists; consider ARNI (sacubitril-valsartan) 1, 2
• Chronic kidney disease with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB mandatory to reduce progressive kidney disease 2
• Previous stroke: ACE inhibitors/ARBs, calcium channel blockers, and diuretics are first-line 1

Absolute Contraindications

• Pregnancy or planning pregnancy: Avoid ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors due to fetal injury/death risk 2
• History of angioedema: Avoid ACE inhibitors 2
• Severe bilateral renal artery stenosis: Avoid ACE inhibitors/ARBs due to acute renal failure risk 2

Monitoring Requirements

Follow-up schedule 1, 2:

• Recheck BP in 1 month after initiating or adjusting therapy 2
• Continue monthly visits until BP controlled 2
• Once controlled, follow-up every 3-6 months 1

Laboratory monitoring 2:

• Check serum creatinine and potassium 7-14 days after starting ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2
• Monitor for hypokalemia when using diuretics 2

Common Pitfalls to Avoid

1. Do not delay pharmacotherapy for a 3-6 month trial of lifestyle modification alone in patients with BP ≥140/90 mmHg—the 2024 European guidelines recommend simultaneous initiation 2

2. Do not use beta-blockers as initial therapy unless specific indications exist (heart failure, coronary disease, post-MI) 1, 2

3. Do not use hydrochlorothiazide when chlorthalidone or indapamide are available—longer-acting thiazide-like diuretics are preferred 2

4. Do not start with monotherapy in patients with Stage 2 hypertension (≥160/100 mmHg) or those >20/10 mmHg above target 1, 2

5. Strongly prefer single-pill combinations to improve adherence and simplify regimens 1, 2