What are the first line therapies for a new diagnosis of hypertension in an adult patient?

First-Line Therapies for New Diagnosis of Hypertension

For most adults with newly diagnosed hypertension, initiate treatment with a thiazide or thiazide-like diuretic (such as chlorthalidone or hydrochlorothiazide), as this class demonstrates the strongest evidence for reducing cardiovascular mortality, stroke, and heart failure. 1, 2

Treatment Initiation Algorithm

Step 1: Confirm Diagnosis and Assess Risk

• Blood pressure should be confirmed on a separate visit if initial reading shows systolic ≥130 mmHg or diastolic ≥80 mmHg 3
• Calculate 10-year atherosclerotic cardiovascular disease (ASCVD) risk to determine treatment urgency 1

Step 2: Determine Treatment Threshold

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

• High-risk patients (10-year ASCVD risk ≥10%, diabetes, chronic kidney disease, or established CVD): Start pharmacotherapy immediately plus lifestyle modifications 1
• Low-risk patients (10-year ASCVD risk <10%): Attempt lifestyle modifications alone for 3-6 months before initiating medication 1, 2, 4

Stage 2 Hypertension (≥140/90 mmHg):

• Initiate two medications from different first-line classes immediately, combined with lifestyle modifications 3, 1, 2

Step 3: Select First-Line Medication Class

The four equally effective first-line options are:

1. Thiazide or thiazide-like diuretics (preferred for most patients) 3, 1, 2, 4
2. ACE inhibitors 3, 1, 2, 4
3. Angiotensin receptor blockers (ARBs) 3, 1, 2, 4
4. Long-acting calcium channel blockers 3, 1, 2, 4

Thiazide diuretics are the preferred initial choice because they enhance the efficacy of multidrug regimens, are more affordable, and have the most robust evidence for reducing heart failure specifically 3, 2

Special Population Modifications

Black Patients Without Heart Failure or CKD:

• Start with calcium channel blocker or thiazide diuretic rather than ACE inhibitor or ARB, as these are more effective as monotherapy in this population 1, 2

Patients with Albuminuria (any degree):

• ACE inhibitor or ARB is mandatory first-line therapy because these agents reduce proteinuria and slow kidney disease progression beyond blood pressure reduction alone 3, 1, 2

Patients with Chronic Kidney Disease:

• ACE inhibitor or ARB required as first-line to provide renoprotection and slow CKD progression 3, 1
• Accept creatinine increases up to 30% from baseline after initiation—this reflects beneficial reduction in intraglomerular pressure 1

Patients with Coronary Artery Disease:

• ACE inhibitor or ARB should be selected as first-line therapy 1

Patients with Diabetes:

• All four first-line classes are equally effective 3, 2
• If albuminuria present (UACR ≥30 mg/g), ACE inhibitor or ARB is mandatory 3, 1
• Target blood pressure <130/80 mmHg 3, 1

Specific Dosing for Stage 1 Hypertension

If starting with lisinopril (ACE inhibitor):

• Initial dose: 10 mg once daily 5
• Titrate to 20-40 mg daily based on response 5
• If taking diuretics, start with 5 mg once daily 5

If starting with thiazide diuretic:

• Hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily 3

Blood Pressure Targets

• Adults <65 years: <130/80 mmHg 1, 4
• Adults ≥65 years: Systolic <130 mmHg 1, 4
• Patients with diabetes or CKD: <130/80 mmHg 3, 1

Essential Lifestyle Modifications (Partially Additive to Medications)

• Dietary sodium restriction: <2,300 mg/day 1, 4
• Weight loss if overweight: Target BMI 18.5-24.9 kg/m² 1, 4
• Aerobic exercise: ≥150 minutes of moderate-intensity activity per week 1, 4
• DASH diet: Emphasize fruits, vegetables, low-fat dairy, reduced saturated fat 1, 4
• Alcohol limitation: ≤14 drinks/week for men, ≤9 drinks/week for women 1
• Smoking cessation 1

Critical Monitoring Requirements

• Follow-up 7-14 days after medication initiation to check serum creatinine and potassium when using ACE inhibitors, ARBs, or diuretics 1, 2
• Monthly follow-up after initiating or changing medications until target blood pressure achieved 2
• Every 3-6 months once blood pressure controlled 2
• Goal: achieve target blood pressure within 3 months 1

Critical Contraindications and Pitfalls

• Never combine ACE inhibitor + ARB simultaneously—this increases adverse effects (hyperkalemia, acute kidney injury) without additional cardiovascular 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 unless patient has ischemic heart disease or heart failure 2
• Discontinue or reduce ACE inhibitor/ARB if potassium >5.5 mEq/L or creatinine increases >30% 1
• Most patients require 2-3 medications to achieve blood pressure targets—do not hesitate to add second agent if monotherapy insufficient after 2-4 weeks 3, 1, 4