What is the first-line treatment for hypertension?

From the Guidelines

First-line treatment for hypertension should typically include thiazide diuretics, such as chlorthalidone, or calcium channel blockers, as these have been shown to be effective in reducing blood pressure and preventing cardiovascular events, as recommended by the 2017 ACC/AHA guideline 1.

Key Considerations

• The selection of initial medication depends on patient characteristics, including age, race, and comorbidities.
• For black patients, thiazide diuretics and calcium channel blockers are preferred due to their efficacy in lowering blood pressure and preventing cardiovascular events, as noted in the 2017 ACC/AHA guideline 1.
• ACE inhibitors and ARBs are also recommended initial choices, particularly for patients with diabetes or chronic kidney disease, as they have been shown to provide renal protection and reduce cardiovascular risk, as discussed in the 2017 ACC/AHA guideline 1.

Medication Options

• Thiazide diuretics: chlorthalidone (12.5-25mg daily) or hydrochlorothiazide (12.5-25mg daily)
• Calcium channel blockers: amlodipine (5-10mg daily)
• ACE inhibitors: lisinopril (10-40mg daily)
• ARBs: losartan (50-100mg daily)

Lifestyle Modifications

• Reducing sodium intake to less than 2.3g daily
• Adopting the DASH diet (rich in fruits, vegetables, and low-fat dairy)
• Regular physical activity (150 minutes of moderate-intensity exercise weekly)
• Weight loss if overweight
• Limiting alcohol consumption
• Smoking cessation

Goal of Treatment

• Reduce blood pressure to below 130/80 mmHg for most adults, with regular monitoring to assess efficacy and adjust treatment as needed, as recommended by the 2017 ACC/AHA guideline 1.

From the FDA Drug Label

Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits The first line treatment for hypertension is not explicitly stated in the provided drug labels.

• The National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) guidelines are mentioned as a reference for specific advice on goals and management, but the guidelines themselves are not provided.
• Lisinopril and losartan are both indicated for the treatment of hypertension, but the labels do not specify that they are first-line treatments.
• The labels suggest that control of high blood pressure should be part of comprehensive cardiovascular risk management, including lifestyle modifications and other therapies as needed. 2 2 3

From the Research

First-Line Treatment for Hypertension

• The first-line treatment for hypertension is often debated, but several studies suggest that thiazide diuretics are a preferred option 4, 5, 6, 7, 8.
• Thiazide diuretics, such as chlortalidone and hydrochlorothiazide, have been shown to be effective in reducing blood pressure and preventing cardiovascular events 5, 6, 7, 8.
• A study published in 2000 found that low-dose thiazides are preferable to high-dose thiazides and are better than or equivalent to other antihypertensive drugs for decreasing morbidity and mortality associated with hypertension 4.
• Another study published in 2014 concluded that chlortalidone is the preferred thiazide diuretic for the treatment of primary hypertension, and that hydrochlorothiazide is a reasonable alternative if chlortalidone is not available 5.
• A 2016 study found that diuretics, including thiazide diuretics, are effective in decreasing blood pressure in hypertensive patients and reducing the risk of adverse cardiovascular outcomes 6.
• A 2023 systematic review and meta-analysis found that first-line thiazide diuretics are likely to reduce cardiovascular events and withdrawals due to adverse effects compared to other antihypertensive drug classes, including beta-blockers, calcium channel blockers, and ACE inhibitors 7.
• A 2024 study discussed the evolving role of chlorthalidone and hydrochlorothiazide as first-line treatments for hypertensive patients, highlighting the importance of considering side effects and patient outcomes when choosing a medication 8.

Comparison of Thiazide Diuretics to Other Antihypertensive Drugs

• Thiazide diuretics have been compared to other antihypertensive drug classes, including beta-blockers, calcium channel blockers, ACE inhibitors, and alpha-blockers 5, 7.
• The comparisons have shown that thiazide diuretics are likely to reduce cardiovascular events and withdrawals due to adverse effects compared to these other drug classes 7.
• However, the choice of medication should be individualized based on patient characteristics, comorbidities, and side effect profiles 8.

Side Effects and Patient Outcomes

• Thiazide diuretics can cause side effects, including hyperglycemia and diabetes, but these do not reduce their efficacy in preventing cardiovascular events 5, 8.
• The choice of thiazide diuretic, either chlortalidone or hydrochlorothiazide, should be based on patient outcomes and side effect profiles 8.