What are good treatments for a patient with hypertension?

Treatment Options for Hypertension

For most adults with hypertension, start immediately with combination therapy using two first-line agents—an ACE inhibitor or ARB plus either a calcium channel blocker or thiazide diuretic—while simultaneously implementing lifestyle modifications, targeting a blood pressure below 140/90 mmHg (or below 130/80 mmHg for higher-risk patients). 1, 2

Initial Pharmacological Therapy

Combination therapy is superior to monotherapy and should be initiated at diagnosis for confirmed hypertension (BP ≥140/90 mmHg): 2

• For non-Black patients: Start with an ACE inhibitor (such as lisinopril) or ARB (such as losartan) combined with either a dihydropyridine calcium channel blocker (such as amlodipine) or a thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide). 1, 2, 3

• For Black patients: A calcium channel blocker combined with a thiazide diuretic is more effective than combinations including an ACE inhibitor or ARB. 1, 2

• Single-pill combinations are strongly preferred over separate medications to improve adherence and treatment persistence. 1

Lifestyle Modifications (Implement Simultaneously, Not Sequentially)

All hypertensive patients should receive comprehensive lifestyle counseling at diagnosis, as these interventions provide additive blood pressure reductions of 10-20 mmHg and enhance medication efficacy: 4, 2, 5

• Sodium restriction to <2g/day produces 5-10 mmHg systolic reduction, with greater benefit in elderly patients. 1, 2, 3

• Weight reduction to achieve BMI 20-25 kg/m² results in 6.0 mmHg systolic and 4.6 mmHg diastolic reduction (approximately 1 mmHg per kg lost). 4, 2, 6

• DASH diet (Dietary Approaches to Stop Hypertension) reduces systolic BP by 11.4 mmHg and diastolic BP by 5.5 mmHg more than control diet—this is the most effective dietary intervention. 1, 5, 3

• Regular aerobic exercise (minimum 30 minutes most days) produces 4 mmHg systolic and 3 mmHg diastolic reduction. 4, 1, 2

• Alcohol limitation: Maximum 21 units/week for men and 14 units/week for women, with alcohol-free days each week. 4, 3, 6

• Smoking cessation should be strongly urged, as the cardiovascular risk from smoking outweighs the benefit of blood pressure control alone. 4, 2

Treatment Escalation Algorithm

If blood pressure remains uncontrolled after 2-4 weeks on dual therapy at optimal doses, add a third agent from the remaining first-line class: 1, 2

• The standard triple therapy combination is ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic. 1, 2, 3

• Chlorthalidone 12.5-25mg daily is preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes. 1, 3

• Never combine an ACE inhibitor with an ARB—this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit. 1, 2

Resistant Hypertension (Uncontrolled on Triple Therapy)

If blood pressure remains ≥140/90 mmHg despite three optimally-dosed medications including a diuretic, add spironolactone 25-50mg daily as the preferred fourth-line agent: 1, 2

• Spironolactone provides additional BP reductions of 20-25/10-12 mmHg when added to triple therapy. 1, 2

• Monitor potassium closely when combining spironolactone with an ACE inhibitor or ARB due to significant hyperkalemia risk. 1

• Before adding a fourth agent, verify medication adherence (the most common cause of apparent treatment resistance) and rule out secondary hypertension causes including primary aldosteronism, renal artery stenosis, and obstructive sleep apnea. 1, 2

Blood Pressure Targets

• Most adults: <140/90 mmHg minimum, with optimal target of 120-139 mmHg systolic if well tolerated. 1, 2, 3

• Higher-risk patients (diabetes, chronic kidney disease, established cardiovascular disease): <130/80 mmHg. 1, 2, 3

• Elderly patients: Target SBP <130 mmHg; do not withhold appropriate treatment based solely on age. 2

Monitoring Strategy

• Confirm diagnosis with out-of-office measurements: Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms true hypertension. 1, 2

• Reassess within 2-4 weeks after any medication adjustment, with the goal of achieving target BP within 3 months of treatment initiation or modification. 1, 2

• Check serum potassium and creatinine 2-4 weeks after initiating or uptitrating ACE inhibitors, ARBs, or diuretics to detect hyperkalemia or changes in renal function. 1

Critical Pitfalls to Avoid

• Do not use monotherapy as initial treatment for confirmed hypertension—combination therapy is more effective and achieves target BP faster. 2

• Do not add beta-blockers as third-line agents unless there are compelling indications (angina, post-MI, heart failure with reduced ejection fraction, or rate control needs)—they are less effective than diuretics for stroke prevention. 1, 2

• Do not delay treatment intensification in patients with stage 2 hypertension (≥160/100 mmHg)—prompt action reduces cardiovascular risk. 1

• Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with heart failure due to negative inotropic effects. 1