What is the best initial antihypertensive medication for a patient with newly diagnosed hypertension and blood pressure readings of 144/93, 135/76, 134/78, and 151/75?

Initial Antihypertensive Medication Selection

For a patient with Stage 1 hypertension (BP readings 144/93,135/76,134/78,151/75), start with a single agent from one of four first-line classes: thiazide-like diuretic (preferably chlorthalidone), ACE inhibitor, ARB, or dihydropyridine calcium channel blocker. 1, 2

Blood Pressure Classification and Treatment Threshold

• Your BP readings average approximately 141/81 mmHg, which classifies as Stage 1 hypertension (130-139/80-89 mmHg), requiring pharmacologic therapy in addition to lifestyle modifications 1
• Since your BP is between 130/80 and 160/100 mmHg, single-drug therapy is appropriate rather than starting with two medications 1
• BP ≥150/90 mmHg would warrant immediate two-drug combination therapy, but your readings do not consistently meet this threshold 1, 2

First-Line Medication Options

The following four drug classes have proven cardiovascular benefit and are appropriate initial choices:

Thiazide-Like Diuretics (Preferred Option)

• Chlorthalidone is the preferred thiazide-like diuretic over hydrochlorothiazide due to superior 24-hour BP control, longer half-life, and stronger cardiovascular outcomes data 1, 2, 3
• In the ALLHAT trial, chlorthalidone was superior to amlodipine and lisinopril in preventing heart failure 1
• Typical starting dose: chlorthalidone 12.5-25 mg once daily 2

ACE Inhibitors

• Appropriate first-line choice with proven cardiovascular and renal protection 1
• Examples: lisinopril 10 mg daily, enalapril 5 mg daily 1, 4
• Particularly indicated if you have: coronary artery disease, diabetes with albuminuria (≥30 mg/g), or chronic kidney disease 1

Angiotensin Receptor Blockers (ARBs)

• Equivalent cardiovascular protection to ACE inhibitors with better tolerability (less cough, less angioedema) 1, 5
• Examples: losartan 50 mg daily, candesartan, telmisartan 6, 3
• Particularly indicated if you have: coronary artery disease, diabetes with albuminuria, or if ACE inhibitor causes intolerable cough 1

Dihydropyridine Calcium Channel Blockers

• Equally effective as thiazides for all cardiovascular outcomes except heart failure prevention 1, 3
• Example: amlodipine 5 mg daily 1, 2
• Good alternative if thiazides are not tolerated 1

Specific Selection Algorithm

Choose your initial medication based on the following hierarchy:

1. If you have diabetes with albuminuria (≥30 mg/g): Start with ACE inhibitor or ARB 1

2. If you have coronary artery disease: Start with ACE inhibitor or ARB 1

3. If you have chronic kidney disease with proteinuria: Start with ACE inhibitor or ARB 1, 7

4. If you are Black (without the above conditions): Thiazide-like diuretic or calcium channel blocker are more effective than ACE inhibitors/ARBs as monotherapy 1, 2, 7

5. If none of the above apply: Thiazide-like diuretic (chlorthalidone) is the preferred first choice based on superior outcomes data, particularly for heart failure prevention 1, 2

Target Blood Pressure and Monitoring

• Target BP: <130/80 mmHg for most adults under 65 years 1, 2, 3
• Reassess BP within 1 month after starting medication to evaluate response 1, 2
• If target not achieved with monotherapy at maximum tolerated dose, add a second agent from a different class 1, 2
• Most patients ultimately require two or more medications to achieve BP control 1, 7

Critical Monitoring Parameters

• Serum creatinine and potassium should be checked within 7-14 days after starting ACE inhibitor or ARB, then at least annually 1
• Urine albumin-to-creatinine ratio should be assessed if diabetes or chronic kidney disease is present 1
• Home BP monitoring is recommended to confirm office readings and assess 24-hour control 1, 2

Common Pitfalls to Avoid

• Do not combine ACE inhibitor with ARB - this increases risk of hyperkalemia and acute kidney injury without additional benefit 1, 7
• Do not use beta-blockers as first-line therapy unless you have prior MI, active angina, or heart failure with reduced ejection fraction 1
• Do not use hydrochlorothiazide when chlorthalidone is available - chlorthalidone has superior outcomes data 1, 2
• Avoid starting with two medications unless BP is ≥160/100 mmHg or ≥150/90 mmHg 1, 2

Lifestyle Modifications (Essential Adjunct)

• Sodium restriction to <2,300 mg/day with increased potassium intake 1, 2, 3
• DASH or Mediterranean diet pattern 1, 2
• Weight loss if BMI >25 kg/m² - target BMI 20-25 kg/m² 2, 3
• 150 minutes/week moderate-intensity aerobic exercise plus resistance training 2-3 times/week 2, 3
• Limit alcohol consumption and tobacco cessation 2, 3