What is the recommended initial management for an adult newly diagnosed with hypertension, including lifestyle interventions, blood pressure targets, and first‑line pharmacologic therapy based on comorbidities?

Initial Management of Newly Diagnosed Hypertension in Adults

Blood Pressure Thresholds for Pharmacologic Treatment

For adults with confirmed hypertension ≥140/90 mmHg, initiate pharmacologic therapy immediately alongside lifestyle modifications, using combination therapy with two drugs from different classes as the preferred initial approach. 1

• Patients with existing cardiovascular disease and systolic BP 130-139 mmHg should start pharmacologic treatment (strong recommendation). 1
• Those without cardiovascular disease but with high cardiovascular risk, diabetes mellitus, or chronic kidney disease and systolic BP 130-139 mmHg may benefit from treatment (conditional recommendation). 1
• Confirm the diagnosis with home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before initiating therapy when feasible, but do not delay treatment. 1, 2

First-Line Pharmacologic Therapy

Start with a two-drug combination from the following classes: thiazide/thiazide-like diuretics, ACE inhibitors, angiotensin receptor blockers, or long-acting dihydropyridine calcium channel blockers—preferably as a single-pill combination to improve adherence. 1, 2

Recommended Initial Combinations

• For non-Black patients: ACE inhibitor or ARB + calcium channel blocker, OR ACE inhibitor or ARB + thiazide diuretic. 2, 3
• For Black patients: Calcium channel blocker + thiazide diuretic is preferred, as this population responds less effectively to ACE inhibitors or ARBs as monotherapy. 2, 3
• For patients with diabetes or chronic kidney disease: ACE inhibitor or ARB should be included in the regimen to improve kidney outcomes. 3, 4
• For patients with established cardiovascular disease: ACE inhibitor or ARB + calcium channel blocker or thiazide diuretic. 1

Specific Drug Examples

• Thiazide-like diuretics: chlorthalidone 12.5-25 mg daily (preferred) or hydrochlorothiazide 25 mg daily. 5
• ACE inhibitors: lisinopril 10-20 mg daily or enalapril 5-10 mg daily. 5
• ARBs: losartan 50 mg daily or candesartan 8-16 mg daily. 5
• Calcium channel blockers: amlodipine 5-10 mg daily. 5

Blood Pressure Targets

Target blood pressure <140/90 mmHg for all patients without comorbidities (strong recommendation), with an optimal goal of 120-129 mmHg systolic if well tolerated. 1, 2

• Patients with known cardiovascular disease should target systolic BP <130 mmHg (strong recommendation). 1
• High-risk patients (high cardiovascular risk, diabetes, chronic kidney disease) should aim for systolic BP <130 mmHg (conditional recommendation). 1
• For adults ≥65 years, target systolic BP <130 mmHg. 5
• Avoid lowering diastolic BP below 60 mmHg in patients with high cardiovascular risk and treated systolic BP <130 mmHg, as this may increase cardiovascular events. 1

Lifestyle Interventions (Initiate Simultaneously with Medications)

Lifestyle modifications should begin at the same time as pharmacologic therapy, not sequentially, as they provide additive blood pressure reductions of 10-20 mmHg. 2, 5

• Sodium restriction to <2 g/day: Reduces systolic BP by 5-10 mmHg. 5
• DASH dietary pattern: High in fruits, vegetables, whole grains, low-fat dairy; low in saturated fat—reduces BP by approximately 11.4/5.5 mmHg. 5
• Weight loss: A 10 kg reduction decreases BP by approximately 6.0/4.6 mmHg in overweight/obese patients. 5
• Regular aerobic exercise: ≥30 minutes most days (≥150 minutes/week moderate intensity) lowers BP by approximately 4/3 mmHg. 5
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women. 5
• Smoking cessation: Mandatory for cardiovascular risk reduction. 5

Laboratory Testing and Comorbidity Screening

Obtain baseline tests to screen for comorbidities when starting therapy, but only when testing does not delay treatment initiation. 1

• Check serum potassium and creatinine 2-4 weeks after initiating ACE inhibitors, ARBs, or diuretics to detect hyperkalemia or changes in renal function. 2
• Cardiovascular risk stratification can be performed after treatment initiation if feasible and does not delay therapy. 1

Monitoring and Follow-Up

Reassess blood pressure monthly after initiation or change in medications until target is reached, then every 3-5 months for patients under control. 1

• Re-measure BP within 2-4 weeks of starting or adjusting therapy. 2
• Achieve target BP within 3 months of initiating or modifying treatment. 2
• Use home BP monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) to confirm control. 2

Escalation to Triple Therapy

If BP remains ≥140/90 mmHg despite dual therapy at optimal doses, add a third agent from the remaining class to create the standard triple regimen: ACE inhibitor or ARB + calcium channel blocker + thiazide diuretic. 1, 2

• Optimize doses of the first two agents before adding a third drug. 1
• Single-pill combinations are strongly preferred to improve adherence. 1, 2

Critical Pitfalls to Avoid

• Do not delay pharmacologic treatment in patients with BP ≥140/90 mmHg while attempting lifestyle modifications alone—start both simultaneously. 2
• Do not combine an ACE inhibitor with an ARB (dual renin-angiotensin system blockade), as this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit. 1
• Do not use beta-blockers as first-line therapy unless there are compelling indications (angina, post-myocardial infarction, heart failure with reduced ejection fraction, atrial fibrillation requiring rate control). 1, 3
• Do not start with monotherapy in patients with stage 2 hypertension (≥160/100 mmHg)—initiate two-drug combination therapy immediately. 2
• Do not assume treatment failure without first confirming medication adherence, as non-adherence is the most common cause of apparent treatment resistance. 1

Special Populations

• Elderly patients (≥85 years) or those with moderate-to-severe frailty: Consider less stringent targets and carefully evaluate for orthostatic hypotension. 2
• Patients with chronic kidney disease: ACE inhibitor or ARB should be included to improve kidney outcomes (moderate evidence). 1, 3
• Black patients with diabetes: Calcium channel blocker or thiazide diuretic is recommended as initial therapy. 3

Administration by Non-Physician Professionals

Pharmacologic treatment can be provided by non-physician professionals (pharmacists, nurses) with proper training, prescribing authority, specific management protocols, and physician oversight. 1