What is the first line of management for an adult patient with newly diagnosed hypertension and no significant comorbidities?

First-Line Hypertension Management

For adults with newly diagnosed hypertension without significant comorbidities, initiate lifestyle modifications immediately, and add pharmacological therapy based on blood pressure stage and cardiovascular risk—specifically, start medications for Stage 2 hypertension (≥140/90 mmHg) or Stage 1 hypertension (130-139/80-89 mmHg) with 10-year ASCVD risk ≥10%. 1

Initial Assessment and Risk Stratification

Before initiating treatment, confirm the diagnosis using proper blood pressure measurement technique with validated devices and exclude white coat hypertension through home blood pressure monitoring or ambulatory monitoring, particularly in patients with Stage 1 hypertension and low cardiovascular risk. 1

Obtain baseline laboratory evaluation including: 1

• Fasting glucose and hemoglobin A1C (A1C detects pre-diabetes/early diabetes when fasting glucose may be normal)
• Complete blood count
• Lipid profile
• Serum creatinine with estimated GFR
• Urinalysis
• TSH
• Electrocardiogram

Calculate 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations for all patients with Stage 1 hypertension to guide treatment decisions. 1

Lifestyle Modifications (Universal First-Line)

Implement the following evidence-based lifestyle interventions for ALL hypertensive patients, regardless of whether medications are started: 1, 2

• Sodium restriction: Reduce intake to <1,500 mg/day, or at minimum achieve an absolute reduction of 1,000 mg/day 1
• Potassium supplementation: Increase dietary potassium to 3,500-5,000 mg/day (unless contraindicated by kidney disease) 1
• Weight loss: Target ideal body weight or minimum 1 kg reduction if overweight/obese 1
• DASH diet: Emphasize fruits, vegetables, whole grains, low-fat dairy products, and reduced saturated/total fat 1, 2
• Physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise, or 3 sessions/week of isometric resistance training 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1

The DASH diet may be the single most effective lifestyle intervention for blood pressure reduction. 3

Pharmacological Therapy: When to Start

Stage 1 Hypertension (130-139/80-89 mmHg)

Low cardiovascular risk (<10% 10-year ASCVD risk):

• Lifestyle modifications ONLY 1
• Recheck blood pressure in 3-6 months 1
• Do NOT initiate medications, as HOPE-3 trial showed no benefit in low-risk patients 1

High cardiovascular risk (≥10% 10-year ASCVD risk):

• Start single-agent pharmacotherapy PLUS lifestyle modifications 1
• Recheck blood pressure in 1 month 1

Stage 2 Hypertension (≥140/90 mmHg)

Initiate combination therapy with TWO antihypertensive agents from different classes PLUS lifestyle modifications immediately, regardless of cardiovascular risk. 1, 4

• Single-pill combinations are strongly preferred to improve adherence 4
• Recheck blood pressure in 1 month 1, 4

Hypertensive Urgency (≥180/110 mmHg)

Prompt evaluation and immediate antihypertensive drug treatment is required. 1

First-Line Medication Classes

The four preferred first-line drug classes are: 1, 2, 5

1. Thiazide/thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes data) 4
2. ACE inhibitors (e.g., lisinopril 10 mg daily initially, usual range 20-40 mg daily) 6
3. Angiotensin receptor blockers (ARBs)
4. Calcium channel blockers (dihydropyridine type, e.g., amlodipine)

Preferred Combination Regimens for Stage 2 Hypertension

Choose one of these evidence-based two-drug combinations: 1, 4

• ACE inhibitor + thiazide-like diuretic
• ACE inhibitor + calcium channel blocker
• ARB + calcium channel blocker
• ARB + thiazide-like diuretic

The most common three-drug combination when escalation is needed: A RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1

Blood Pressure Targets

Target systolic blood pressure of 120-129 mmHg for most adults when well tolerated. 1

• For adults <65 years: <130/80 mmHg 1, 4
• For adults ≥65 years: <130 mmHg systolic 4, 2
• If treatment is poorly tolerated, target "as low as reasonably achievable" (ALARA principle) 1

Titration Strategy and Follow-Up

Monthly follow-up is recommended until blood pressure is controlled. 1

• Monitor serum creatinine and potassium 7-14 days after starting ACE inhibitors, ARBs, or diuretics 4
• If blood pressure goal not achieved within 3 months on two agents, escalate to three-drug combination 1, 4
• Increase dose of single agent to maximum before adding second agent in Stage 1 hypertension 7

Critical Pitfalls to Avoid

Do NOT combine ACE inhibitor + ARB + renin inhibitor—this is potentially harmful and contraindicated. 1, 4

Do NOT delay pharmacotherapy for lifestyle modification trial alone in Stage 2 hypertension—this increases cardiovascular risk unnecessarily. 4

Do NOT start with monotherapy in Stage 2 hypertension—combination therapy achieves control faster and improves outcomes. 4

Do NOT use hydrochlorothiazide when chlorthalidone is available—chlorthalidone has superior cardiovascular outcomes data. 4

Do NOT overlook secondary hypertension screening in patients with: 1

• Hypertension onset <30 years of age
• Resistant hypertension (uncontrolled on 3+ drugs including diuretic)
• Abrupt onset or loss of prior blood pressure control
• Unprovoked or excessive hypokalemia