What is the recommended management plan for an adult with primary (essential) hypertension and no contraindications to standard therapy?

Hypertension Management in Adults

Initial Treatment Strategy

For adults with primary hypertension and no contraindications, initiate pharmacological therapy with a thiazide-type diuretic (preferably chlorthalidone 12.5-25 mg daily), ACE inhibitor, ARB, or long-acting calcium channel blocker, combined with lifestyle modifications, targeting a blood pressure <130/80 mmHg for most patients. 1, 2, 3

Blood Pressure Targets

• Target <130/80 mmHg for most adults under 65 years with hypertension, particularly those with known cardiovascular disease or 10-year ASCVD risk ≥10% 1, 2, 3
• Target systolic <130 mmHg for adults ≥65 years who are noninstitutionalized, ambulatory, and community-living 1, 2
• The European Society of Cardiology recommends a systolic target of 120-129 mmHg when treatment is well tolerated 2

Pharmacological Therapy Algorithm

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

• Begin with single-agent therapy using one of four first-line drug classes 2, 4:
  • Thiazide-type diuretic: Chlorthalidone 12.5-25 mg once daily (preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 3, 5
  • ACE inhibitor: Lisinopril 10 mg once daily (usual range 20-40 mg daily) 2, 6
  • ARB: Losartan 50-100 mg once daily 3
  • Long-acting calcium channel blocker: Amlodipine 5-10 mg once daily 3, 7

Stage 2 Hypertension (BP ≥140/90 mmHg or ≥20/10 mmHg above target)

• Initiate combination therapy with two drugs from different classes, preferably as a single-pill combination to improve adherence 1, 2, 4
• Preferred two-drug combinations 1, 2, 3:
  • ACE inhibitor or ARB + calcium channel blocker
  • ACE inhibitor or ARB + thiazide diuretic
  • Calcium channel blocker + thiazide diuretic
• Example regimen: Chlorthalidone 12.5-25 mg + lisinopril 10 mg daily 2

Resistant Hypertension (Uncontrolled on Three Drugs)

• Optimize the three-drug combination (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) before adding a fourth agent 2, 3
• Add spironolactone 25-50 mg daily as the preferred fourth-line agent 2, 3
• Consider referral to hypertension specialist if BP remains uncontrolled 1

Population-Specific Considerations

Black Patients

• Initiate therapy with a calcium channel blocker or thiazide diuretic rather than ACE inhibitor or ARB monotherapy, as these are more effective in this population 2, 4, 8
• Combination of calcium channel blocker + thiazide diuretic may be particularly effective 3

Patients with Comorbidities

• Coronary artery disease: ACE inhibitor or ARB as first-line 2, 4
• Albuminuria (UACR ≥30 mg/g) or chronic kidney disease: ACE inhibitor or ARB mandatory as initial therapy to reduce progressive kidney disease 2, 4
• Heart failure: Beta-blockers indicated in addition to other agents 2
• Diabetes: ACE inhibitor or ARB preferred 3, 8

Pregnancy Considerations

• ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and direct renin inhibitors are absolutely contraindicated due to risk of fetal injury and death 2

Lifestyle Modifications (Concurrent with Pharmacotherapy)

• DASH dietary pattern: 8-10 servings of fruits/vegetables daily, 2-3 servings of low-fat dairy 2
• Sodium restriction: <2,300 mg/day 2
• Weight loss for overweight individuals through caloric restriction 2
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week 2
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 2
• Smoking cessation for all patients 2

Monitoring and Follow-Up

• Recheck BP within 1 month after initiating or adjusting therapy, with goal of achieving target within 3 months 2, 3, 4
• Monitor serum creatinine, potassium, and sodium 7-14 days after starting ACE inhibitors, ARBs, or diuretics to detect hyperkalemia, hypokalemia, or acute kidney injury 2, 3
• Titrate medications or add additional agents if BP goals not achieved 2
• Once controlled, follow-up every 3-5 months 4

Critical Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB), as this increases adverse events without additional cardiovascular benefit 1, 2, 3, 4
• Do not delay pharmacotherapy for a trial of lifestyle modification alone in patients with BP ≥140/90 mmHg; initiate both simultaneously 2
• Avoid hydrochlorothiazide when chlorthalidone is available, as longer-acting thiazide-like diuretics have superior outcomes 2, 5
• Avoid beta-blockers as initial therapy unless specific indication exists (heart failure, coronary disease, prior MI) 4
• Confirm medication adherence before escalating therapy, as non-adherence is the most common cause of apparent treatment resistance 3
• Avoid ACE inhibitors in patients with history of angioedema or bilateral renal artery stenosis 2

Dosing Guidance from FDA Label

• Lisinopril initial dose: 10 mg once daily, with usual dosage range 20-40 mg daily 6
• When adding a diuretic to lisinopril: Start with hydrochlorothiazide 12.5 mg; may reduce lisinopril dose to 5 mg once daily 6
• Doses up to 80 mg lisinopril have been used but do not provide greater effect 6