What is the first-line treatment for a normal weight patient with no medical history and newly diagnosed Hypertension with a blood pressure of 170/90 mmHg?

First-Line Hypertensive Management for BP 170/90s

Start immediate pharmacological treatment with an ACE inhibitor (such as lisinopril 10 mg daily) or ARB (such as losartan 50 mg daily) as this represents Grade 2 Hypertension requiring prompt drug therapy. 1

Confirming the Diagnosis

• Take at least two additional blood pressure measurements using a validated device with appropriate cuff size to confirm the elevated readings before initiating treatment 1
• Consider home blood pressure monitoring to track progress and improve medication adherence 1

Immediate Pharmacological Treatment

This patient has Grade 2 Hypertension (≥160/100 mmHg) and requires immediate drug treatment, not a trial of lifestyle modifications alone. 1

For Non-Black Patients (First-Line):

• Start with low-dose ACE inhibitor or ARB 1, 2
  • Lisinopril 10 mg once daily 2
  • OR Losartan 50 mg once daily 2, 3
• These medications reduce BP by approximately 15.5/9.2 mmHg when losartan 50 mg is used 3

For Black Patients (First-Line):

• Start with an ARB plus dihydropyridine calcium channel blocker (DHP-CCB) such as amlodipine 1
• OR start with a DHP-CCB plus thiazide-like diuretic 1
• Thiazide-like diuretics (chlorthalidone 12.5-25 mg daily) or DHP-CCB (amlodipine 5 mg daily) are preferred as monotherapy in Black patients 2

Important caveat: Losartan and other ARBs are somewhat less effective in Black patients due to typically lower renin levels, which is why combination therapy or alternative first-line agents are recommended 3

Blood Pressure Targets and Timeline

• Initial goal: Reduce BP by at least 20/10 mmHg 1
• Target BP: <130/80 mmHg 1, 4
• Achieve target within 3 months of initiating therapy 1, 2

Concurrent Lifestyle Modifications

While pharmacological treatment is mandatory at this BP level, lifestyle changes provide additive benefits 2, 4:

• Dietary sodium restriction to <2,300 mg/day, ideally <2,000 mg/day 2
• DASH diet pattern: 8-10 servings of fruits and vegetables daily, whole grains, low-fat dairy, lean proteins 2
• Regular aerobic exercise: At least 150 minutes per week of moderate-intensity activity 2
• Weight loss if overweight (though this patient is normal weight) 4
• Limit alcohol consumption 4

The BP-lowering effects of lifestyle modifications are partially additive and enhance medication efficacy 4

Monitoring and Follow-Up

• Schedule follow-up within 2-4 weeks to assess response to therapy and check for adverse effects 1, 2
• Monitor for medication adherence and side effects 1
• If starting an ACE inhibitor or ARB, check renal function and potassium levels 2-4 weeks after initiation 2

Medication Titration Strategy

If BP remains uncontrolled after 2-4 weeks 2:

1. First step: Optimize the initial medication dose to maximum (losartan up to 100 mg daily or lisinopril up to 40 mg daily) 2, 3

2. Second step: Add a second agent from a different class 1, 2:

   • Preferred addition: Calcium channel blocker (amlodipine 5-10 mg daily) 1, 5
   • Alternative: Thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) 1
   • CCB is preferred over thiazide diuretic to reduce diabetes risk 1

3. Third step: If still uncontrolled on two medications, add a third agent from the remaining class 1

When to Refer to Specialist

• Refer to hypertension specialist if BP remains uncontrolled despite multiple medications 1
• Consider referral for resistant hypertension (uncontrolled on three or more medications including a diuretic) 1
• Assess for secondary causes of hypertension, particularly with severe or resistant hypertension 1

Common Pitfalls to Avoid

• Do not delay pharmacological treatment in favor of lifestyle modifications alone at this BP level—this is Grade 2 Hypertension requiring immediate drug therapy 1
• Do not use immediate-release nifedipine for hypertension management 6
• Avoid rapid BP reduction unless this is a hypertensive emergency with acute end-organ damage 6
• Do not start with combination therapy initially unless BP is significantly higher; monotherapy is appropriate for this patient 2