What is the first line treatment for a typical adult patient with primary hypertension?

First-Line Hypertension Treatment

For a typical adult patient with primary hypertension, initiate treatment with one of four first-line medication classes: thiazide or thiazide-like diuretics (chlorthalidone preferred), ACE inhibitors, ARBs, or calcium channel blockers, combined with lifestyle modifications targeting blood pressure <130/80 mmHg. 1

Treatment Initiation Thresholds

• Pharmacological therapy should be initiated when blood pressure is ≥140/90 mmHg in most patients 1
• For high-risk patients (established cardiovascular disease, diabetes, or chronic kidney disease), initiate pharmacological therapy at ≥130/80 mmHg 1
• For stage 1 hypertension (130-139/80-89 mmHg) with low cardiovascular risk, lifestyle modifications alone for 3-6 months is acceptable before adding medication 1
• For stage 2 hypertension (≥140/90 mmHg), immediately initiate two antihypertensive medications from different classes plus lifestyle modifications 1

First-Line Medication Selection

All four first-line classes are equally effective at reducing cardiovascular morbidity and mortality, but selection should be guided by patient-specific factors 1:

Thiazide or Thiazide-Like Diuretics

• Chlorthalidone and indapamide are preferred over hydrochlorothiazide due to superior cardiovascular outcomes, particularly for heart failure prevention 2
• These agents have the strongest evidence for preventing heart failure events 1

ACE Inhibitors or ARBs

• Mandatory first-line choice for patients with albuminuria (UACR ≥30 mg/g) because they reduce proteinuria and slow kidney disease progression beyond blood pressure reduction alone 1, 2
• Preferred for patients with coronary artery disease 1, 2
• Preferred for patients with chronic kidney disease 1
• ACE inhibitors are FDA-approved for hypertension treatment and reduce cardiovascular morbidity and mortality 3

Calcium Channel Blockers (Dihydropyridine)

• Particularly effective for stroke prevention 2
• More effective than ACE inhibitors or ARBs as monotherapy in Black patients 1, 2

Population-Specific Considerations

Black Patients

• Calcium channel blockers or thiazide diuretics are more effective than ACE inhibitors or ARBs when used as monotherapy 1, 2
• Combination therapy eliminates racial differences in blood pressure response 3

Patients with Diabetes

• ACE inhibitors are reasonable as first-line agents 4
• For those with microalbuminuria or clinical nephropathy, ACE inhibitors (type 1 and type 2) or ARBs (type 2) are first-line therapy 4
• Target blood pressure <130/80 mmHg 4

Patients with Chronic Kidney Disease

• ACE inhibitors or ARBs are first-line drugs because they reduce albuminuria and slow CKD progression 1

Lifestyle Modifications (Essential for All Patients)

• Weight loss through caloric restriction if overweight or obese 1
• Dietary Approaches to Stop Hypertension (DASH) eating pattern with sodium <2,300 mg/day and increased potassium intake 1, 5
• At least 150 minutes of moderate-intensity aerobic exercise per week 1
• Alcohol moderation and smoking cessation 1
• These modifications are partially additive with pharmacological therapy 5

Blood Pressure Targets

• Target <130/80 mmHg for most adults <65 years 1
• Target systolic <130 mmHg for adults ≥65 years 1
• For patients with diabetes: <130/80 mmHg 4

Critical Monitoring Requirements

• Monitor serum creatinine and potassium levels within 7-14 days when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Follow-up 7-14 days after medication initiation or dose changes 1
• Goal is to achieve blood pressure target within 3 months 1

Important Caveats and Pitfalls

• Never combine ACE inhibitors with ARBs—this increases adverse effects without additional benefit 1, 2
• ACE inhibitors and ARBs are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential not using reliable contraception 1
• Beta-blockers are not first-line therapy for uncomplicated hypertension unless there are specific indications (prior MI, active angina, heart failure with reduced ejection fraction) 2
• Most patients will require 3 or more drugs to achieve target blood pressure, particularly those with diabetes 4
• Accept creatinine increases up to 30% from baseline after initiating ACE inhibitors or ARBs—this reflects beneficial reduction in intraglomerular pressure 1
• When initiating ACE inhibitors or ARBs, monitor for hyperkalemia; discontinue or reduce dose if potassium >5.5 mEq/L 1