How should I initially manage a newly diagnosed hypertensive adult, including confirmation of diagnosis, baseline evaluation, lifestyle modifications, and first‑line medication selection based on blood pressure stage and cardiovascular risk?

Initial Hypertensive Management

For newly diagnosed hypertensive adults, confirm the diagnosis with out-of-office blood pressure monitoring, initiate lifestyle modifications immediately, and start pharmacological therapy based on blood pressure stage and cardiovascular risk—specifically, begin single-agent therapy for stage 1 hypertension with low cardiovascular risk, but start dual therapy for stage 2 hypertension (≥140/90 mmHg) or stage 1 with ≥10% 10-year ASCVD risk. 1

Confirming the Diagnosis

Out-of-office confirmation is mandatory before starting treatment:

• Confirm hypertension using home blood pressure monitoring (≥135/85 mmHg average) or 24-hour ambulatory monitoring (≥130/80 mmHg average) to exclude white coat hypertension 1, 2
• Office measurements should use proper technique: patient seated with back supported, feet flat, arm supported at heart level, appropriate cuff size, after 5 minutes of rest 1
• Obtain at least 2 readings per occasion on at least 3 separate days before diagnosing hypertension 1, 3

Baseline Evaluation

Assess cardiovascular risk and target organ damage:

• Calculate 10-year ASCVD risk using the pooled cohort equation to guide treatment intensity 1
• Obtain baseline laboratory studies: serum creatinine/eGFR, electrolytes (sodium, potassium), fasting lipid panel, fasting glucose or HbA1c, urinalysis for proteinuria 1, 3
• Screen for secondary hypertension if: age <30 years, sudden onset, resistant hypertension (uncontrolled on 3 drugs), severe hypertension (≥180/110 mmHg), or suggestive clinical features 4
• Assess for hypertension-mediated organ damage: left ventricular hypertrophy (ECG or echo), retinopathy, chronic kidney disease, albuminuria 1, 5

Lifestyle Modifications (All Patients)

Implement immediately for all patients with BP ≥120/80 mmHg:

• DASH dietary pattern: 8-10 servings fruits/vegetables daily, 2-3 servings low-fat dairy, whole grains, reduced saturated fat—reduces BP by 11.4/5.5 mmHg 1, 2, 6
• Sodium restriction: <2 g/day (approximately 5 g salt)—reduces systolic BP by 5-10 mmHg 1, 2, 6
• Potassium supplementation: increase dietary potassium through fruits and vegetables unless contraindicated by chronic kidney disease 2, 6
• Weight loss: target BMI 20-25 kg/m²; 10 kg loss reduces BP by approximately 6/4.6 mmHg 1, 6
• Physical activity: ≥150 minutes/week moderate-intensity aerobic exercise—reduces BP by 4/3 mmHg 1, 2, 6
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women (≤100 g/week)—excess consumption interferes with BP control 1, 2, 6
• Smoking cessation: mandatory for all patients to reduce cardiovascular risk 2, 3

Pharmacological Therapy: Treatment Algorithm

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

Low cardiovascular risk (<10% 10-year ASCVD risk):

• Manage with lifestyle modifications alone initially 1
• Repeat BP evaluation in 3-6 months 1
• Initiate medication if BP remains elevated after 3-6 months of lifestyle intervention 1

High cardiovascular risk (≥10% 10-year ASCVD risk):

• Start single-agent pharmacotherapy immediately plus lifestyle modifications 1
• Reassess BP in 1 month 1

Stage 2 Hypertension (≥140/90 mmHg)

Initiate dual-agent therapy immediately:

• Start two medications from different classes simultaneously, preferably as a single-pill combination 1, 2, 6
• Dual therapy achieves BP control faster than sequential monotherapy and improves adherence 2
• Reassess BP in 1 month 1

Very High BP (≥180/110 mmHg)

• Prompt evaluation and immediate antihypertensive drug treatment required 1
• Consider starting with two agents at full doses 1

First-Line Medication Selection

Choose from four equally effective first-line classes:

For Non-Black Patients Without Specific Comorbidities:

Preferred initial regimens:

• ACE inhibitor (e.g., lisinopril 10 mg daily, titrate to 20-40 mg) OR ARB (e.g., losartan 50 mg daily, titrate to 100 mg) 1, 2, 6, 5
• Thiazide-like diuretic: chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcomes) 1, 2, 6
• Calcium channel blocker: amlodipine 5 mg daily, titrate to 10 mg 1, 2, 6, 5

For dual therapy (stage 2 hypertension):

• ACE inhibitor/ARB + calcium channel blocker, OR
• ACE inhibitor/ARB + thiazide diuretic, OR
• Calcium channel blocker + thiazide diuretic 1, 2

For Black Patients Without Specific Comorbidities:

• Preferred: Calcium channel blocker + thiazide diuretic (more effective than ACE inhibitor/ARB-based regimens in this population) 1, 7
• ACE inhibitors and ARBs are less effective as monotherapy in Black patients but appropriate when combined with other agents 1

Comorbidity-Specific Selections:

Chronic kidney disease or albuminuria (UACR ≥30 mg/g):

• ACE inhibitor or ARB mandatory as initial therapy to reduce progressive kidney disease 1, 2

Coronary artery disease:

• ACE inhibitor or ARB preferred 2
• Add beta-blocker if history of myocardial infarction or angina 1

Heart failure with reduced ejection fraction:

• ACE inhibitor/ARB + beta-blocker + mineralocorticoid receptor antagonist + diuretic 2

Diabetes mellitus:

• ACE inhibitor or ARB preferred 1

Pregnancy or planning pregnancy:

• Contraindicated: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors (fetal injury/death) 2
• Safe options: methyldopa, nifedipine, labetalol 2

Blood Pressure Targets

• Primary target: <130/80 mmHg for most adults <65 years 1, 2, 6
• Older adults ≥65 years: systolic <130 mmHg if tolerated 1, 6
• Optimal target (if well tolerated): systolic 120-129 mmHg 2
• Minimum acceptable: <140/90 mmHg 1, 2
• High-risk patients (diabetes, chronic kidney disease, established CVD): <130/80 mmHg 1, 2

Titration and Escalation Strategy

Achieve target BP within 3 months of initiating therapy:

1. If BP not at goal on single agent: Add second agent from different class (typically ACE inhibitor/ARB + calcium channel blocker or + thiazide diuretic) 1, 2

2. If BP not at goal on two agents: Add third agent to create triple therapy (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1, 2

3. Resistant hypertension (uncontrolled on 3 drugs including diuretic):

   • Verify medication adherence first (most common cause of apparent resistance) 1, 4
   • Optimize diuretic: switch hydrochlorothiazide to chlorthalidone 12.5-25 mg daily 7
   • Add spironolactone 25-50 mg daily as preferred fourth-line agent (reduces BP by additional 20-25/10-12 mmHg) 1, 7, 4
   • Screen for secondary hypertension 4

Monitoring After Medication Initiation

• Recheck BP: 2-4 weeks after starting or changing medication 1, 2
• Laboratory monitoring: Check serum creatinine, eGFR, potassium, and sodium 7-14 days after initiating ACE inhibitor, ARB, or diuretic 2
• Follow-up frequency: Every 1-3 months until BP controlled, then every 3-6 months 2

Critical Pitfalls to Avoid

• Do not delay pharmacotherapy for prolonged lifestyle trial in patients with BP ≥140/90 mmHg—start medications simultaneously with lifestyle changes 2
• Do not use monotherapy for stage 2 hypertension (≥140/90 mmHg)—dual therapy is required 1, 2
• Do not combine ACE inhibitor with ARB—increases hyperkalemia and acute kidney injury risk without cardiovascular benefit 1, 2
• Do not use beta-blockers as first-line unless compelling indication (post-MI, heart failure, angina, atrial fibrillation)—less effective than other classes for stroke prevention 1, 2
• Do not assume treatment failure without first confirming adherence (use pill counts, pharmacy refills, direct questioning) 1, 7
• Do not ignore white coat hypertension—confirm with home or ambulatory monitoring before starting treatment in low-risk patients 1
• Do not use hydrochlorothiazide when chlorthalidone is available—chlorthalidone has superior 24-hour BP control and cardiovascular outcomes 7, 2