What is the first line treatment for a newly diagnosed adult patient with stage 1 hypertension and no underlying severe medical conditions?

First-Line Blood Pressure Treatment for Stage 1 Hypertension

For a newly diagnosed adult with stage 1 hypertension (130-139/80-89 mmHg) and no severe underlying conditions, initiate lifestyle modifications alone if their 10-year ASCVD risk is <10%, but add pharmacological therapy with a single agent from one of four first-line drug classes (thiazide/thiazide-like diuretic, ACE inhibitor, ARB, or long-acting calcium channel blocker) if their 10-year ASCVD risk is ≥10%. 1, 2

Risk Stratification Determines Treatment Intensity

The critical first step is calculating the patient's 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations, as this determines whether pharmacotherapy is needed immediately. 1, 2

For Stage 1 Hypertension with Low Cardiovascular Risk (<10% 10-year ASCVD):

• Start with lifestyle modifications alone and reassess blood pressure in 3-6 months. 1
• Confirm the diagnosis with out-of-office blood pressure monitoring (home or ambulatory) to exclude white coat hypertension before committing to long-term treatment. 1, 3

For Stage 1 Hypertension with High Cardiovascular Risk (≥10% 10-year ASCVD):

• Initiate both lifestyle modifications AND single-agent pharmacotherapy simultaneously. 1, 2
• Reassess blood pressure in 1 month. 1

First-Line Pharmacological Options

When drug therapy is indicated, choose from these four equally effective first-line classes: 1, 2, 4

1. Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide for superior cardiovascular outcomes data) 2
2. ACE inhibitors (e.g., lisinopril, enalapril) 1, 5, 4
3. Angiotensin receptor blockers (ARBs) (e.g., losartan, candesartan) 1, 6, 4
4. Long-acting dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 4

The WHO and ACC/AHA guidelines provide strong recommendations (high-quality evidence) that these four classes are equally effective as monotherapy for initial treatment. 1, 2

Essential Lifestyle Modifications

Implement these evidence-based interventions for all hypertensive patients, as they have additive blood pressure-lowering effects: 1, 2, 4

• Dietary sodium restriction to <1,500 mg/day 2
• Potassium supplementation to 3,500-5,000 mg/day 2
• Weight loss targeting ideal body weight or minimum 1 kg reduction 2, 4
• DASH dietary pattern (rich in fruits, vegetables, whole grains, low-fat dairy) 2, 4
• Physical activity of 90-150 minutes per week 2, 4
• Alcohol moderation to ≤2 drinks/day for men and ≤1 drink/day for women 2, 4

Blood Pressure Targets

Target blood pressure <130/80 mmHg for adults <65 years of age. 2, 3, 4 For adults ≥65 years, target systolic blood pressure <130 mmHg. 2, 3

Monitoring Strategy

• Monthly follow-up visits after initiating or changing antihypertensive medications until target blood pressure is achieved. 1, 2, 3
• Use home blood pressure monitoring as the most practical method for medication titration. 3
• Monitor serum creatinine and potassium 7-14 days after starting ACE inhibitors, ARBs, or diuretics. 2
• If blood pressure goal is not achieved within 3 months on monotherapy, escalate to two-drug combination therapy. 2

Critical Pitfalls to Avoid

• Never combine ACE inhibitor + ARB + renin inhibitor, as this triple combination is potentially harmful and contraindicated. 1, 2
• Do not delay confirming the diagnosis with out-of-office monitoring in low-risk stage 1 hypertension, as this prevents unnecessary treatment of white coat hypertension. 1, 3
• Do not use hydrochlorothiazide when chlorthalidone is available, as chlorthalidone has superior cardiovascular outcomes data. 2
• Recognize that antihypertensive drugs may have smaller blood pressure effects as monotherapy in Black patients, which may influence drug selection. 5, 4