Hypertension Medication Initiation Algorithm
Initial Assessment and Blood Pressure Classification
For most adults with newly diagnosed hypertension, initiate dual-combination therapy immediately rather than monotherapy, using a single-pill combination of an ACE inhibitor or ARB plus either a calcium channel blocker or thiazide diuretic. 1, 2
Blood Pressure Thresholds for Medication Initiation
Stage 1 Hypertension (130-139/80-89 mmHg): Start pharmacologic therapy if the patient has established cardiovascular disease OR 10-year ASCVD risk ≥10% (patients with diabetes or chronic kidney disease are automatically high-risk). 3
Stage 2 Hypertension (≥140/90 mmHg): Initiate pharmacologic therapy immediately for all patients, typically with two antihypertensive agents from different classes. 3, 2
Severely Elevated BP (≥160/100 mmHg): Promptly start dual therapy with careful monitoring and rapid dose titration to achieve control. 3
First-Line Medication Selection Algorithm
For Non-Black Patients
Preferred initial regimen: Low-dose ACE inhibitor or ARB + dihydropyridine calcium channel blocker as a single-pill combination. 1
Alternative option: ACE inhibitor or ARB + thiazide-like diuretic (chlorthalidone 12.5-25mg or hydrochlorothiazide 25mg). 3, 1
Specific drug examples: Lisinopril 10mg + amlodipine 5mg, or enalapril + amlodipine, or candesartan + amlodipine. 4, 5
For Black Patients
Preferred initial regimen: Dihydropyridine calcium channel blocker + thiazide-like diuretic. 1
Alternative option: ARB + dihydropyridine calcium channel blocker. 1
Rationale: Calcium channel blockers and thiazides are more effective than ACE inhibitors/ARBs as monotherapy in Black patients. 3, 1
Special Population Considerations
Patients with Chronic Kidney Disease
First-line therapy: ACE inhibitor or ARB at maximum tolerated dose, especially if albuminuria present (urine albumin-to-creatinine ratio ≥30 mg/g). 1
Add: Calcium channel blocker or thiazide-like diuretic as second agent. 1
Monitoring: Check serum creatinine and potassium 2-4 weeks after initiating or adjusting ACE inhibitor/ARB therapy. 3, 1
Patients with Heart Failure
Compelling indication regimen: ACE inhibitor or ARB + beta-blocker + diuretic (usually loop diuretic if volume overloaded). 3
Starting dose with hyponatremia (serum sodium <130 mEq/L): Lisinopril 2.5mg once daily, titrate as tolerated to maximum 40mg daily. 4
Target BP: <130/80 mmHg. 1
Patients with Impaired Renal Function
Creatinine clearance >30 mL/min: No dose adjustment required for lisinopril. 4
Creatinine clearance 10-30 mL/min: Reduce initial lisinopril dose to 5mg daily for hypertension; titrate to maximum 40mg daily as tolerated. 4
Creatinine clearance <10 mL/min or hemodialysis: Start lisinopril 2.5mg once daily. 4
Stepwise Escalation Protocol
If BP Not Controlled on Dual Therapy (After 3 Months)
Add a third agent from the remaining first-line class to create triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic. 1, 2
Preferred thiazide: Chlorthalidone 12.5-25mg daily (superior to hydrochlorothiazide for 24-hour BP control and cardiovascular outcomes). 1, 6
Optimize doses of existing medications before adding the third agent if BP is 20-30 mmHg above target. 1
Resistant Hypertension (Uncontrolled on Triple Therapy)
Add spironolactone 25-50mg daily as the preferred fourth-line agent. 1, 6
Monitor potassium closely when adding spironolactone to ACE inhibitor/ARB (hyperkalemia risk). 1, 6
Alternative fourth-line agents if spironolactone contraindicated: Amiloride, doxazosin, eplerenone, or clonidine. 6
Blood Pressure Targets
Monitoring Schedule
Initial follow-up: 2-4 weeks after starting or adjusting therapy to assess response, tolerability, and check electrolytes/renal function if using ACE inhibitor/ARB or diuretic. 3, 1
Titration phase: Monthly visits until BP controlled. 1
Target achievement: Within 3 months of initiating or modifying treatment. 1, 2
Maintenance: Every 3-6 months once BP consistently at target. 1
Critical Pitfalls to Avoid
Never combine two RAS blockers (ACE inhibitor + ARB)—this increases hyperkalemia and acute kidney injury without cardiovascular benefit. 1, 6
Never use monotherapy as initial treatment for confirmed hypertension ≥140/90 mmHg—dual therapy is more effective and achieves control faster. 1, 2
Do not add beta-blockers as third-line therapy unless compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, or rate control needed). 6
Avoid clinical inertia—immediate combination therapy is superior to sequential monotherapy titration. 1
Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with heart failure or left ventricular dysfunction. 1, 6
Always verify medication adherence before escalating therapy—non-adherence is the most common cause of apparent treatment resistance. 1, 6
Screen for secondary hypertension if BP remains ≥160/100 mmHg despite triple therapy: primary aldosteronism, renal artery stenosis, obstructive sleep apnea, medication interference (NSAIDs). 1, 6
Lifestyle Modifications (Mandatory for All Patients)
DASH or Mediterranean diet with sodium restriction to <1500 mg/day (or reduce by ≥1000 mg/day). 1
Potassium supplementation 3500-5000 mg/day through dietary sources. 1
Weight loss targeting ideal BMI or minimum 1 kg reduction if overweight. 1
Aerobic exercise 90-150 minutes per week of moderate-intensity activity. 1
Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women. 1
Expected BP reduction from comprehensive lifestyle changes: 10-20 mmHg systolic. 1, 6