What is the first‑line management for a patient with stage 2 hypertension (blood pressure 154/94 mm Hg)?

First-Line Management for Blood Pressure 154/94 mmHg

For a patient with stage 2 hypertension (BP 154/94 mmHg), immediately initiate combination therapy with two antihypertensive agents from different classes plus lifestyle modifications at the first visit. 1, 2

Immediate Pharmacological Therapy

Start dual-agent therapy on day one—do not delay with lifestyle modifications alone. 1, 2

Preferred Two-Drug Combinations:

• ACE inhibitor (or ARB) + calcium channel blocker, OR 2, 3
• ACE inhibitor (or ARB) + thiazide/thiazide-like diuretic 2, 3

Specific Agent Selection:

• For the thiazide component: Use chlorthalidone (12.5-25 mg once daily) rather than hydrochlorothiazide due to superior cardiovascular outcomes and longer half-life 2
• Use single-pill combination formulations when available to improve adherence 2

Race-Based Considerations:

• Non-Black patients: Start with low-dose ACE inhibitor/ARB combined with either a dihydropyridine calcium channel blocker or thiazide-like diuretic 1
• Black patients: Start with low-dose ARB combined with dihydropyridine calcium channel blocker or thiazide-like diuretic 1

Concurrent Lifestyle Modifications (Start Simultaneously)

These must begin immediately alongside medications, not as a trial period before drugs: 1

• Weight loss: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 2
• DASH or Mediterranean diet: Emphasize reduced saturated fat, increased fruits, vegetables, and low-fat dairy 2, 3
• Sodium restriction: Reduce dietary sodium intake 3, 4
• Alcohol limitation: Maximum 100 g/week of pure alcohol 2
• Physical activity: 150 minutes/week of moderate-intensity aerobic exercise plus resistance training 2-3 times weekly 2

Blood Pressure Targets

• Primary target: Systolic BP 120-129 mmHg (if well tolerated) 2
• Minimum acceptable target: <140/90 mmHg 1, 2
• For patients with diabetes or chronic kidney disease: <130/80 mmHg 2, 3

Follow-Up Schedule

• Recheck BP in 1 month after initiating therapy 1, 2
• Monitor electrolytes and renal function 2-4 weeks after starting ACE inhibitor, ARB, or diuretic 2
• Continue monthly visits until BP goal is achieved 2
• Achieve BP control within 3 months of initial diagnosis 1, 2

Escalation Strategy if Uncontrolled After 1 Month

If BP remains ≥140/90 mmHg on two-drug combination: 2

• Add a third agent to create triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 2
• Do not delay escalation—inadequate control increases cardiovascular risk 1

Special Population Modifications

High-Risk Comorbidities:

• Diabetes, CKD, or albuminuria: Prioritize ACE inhibitor or ARB as one of the initial two agents 2, 5
• Coronary artery disease: Prefer ACE inhibitor or ARB 2, 5

Contraindications:

• Pregnant or planning pregnancy: Avoid ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists entirely due to fetal harm 2, 5

Age/Frailty Considerations:

• Age ≥85 years or moderate-to-severe frailty: Consider single-agent therapy instead of combination therapy 2
• Otherwise, age alone does not justify monotherapy for stage 2 hypertension 1

Critical Pitfalls to Avoid

• Never use monotherapy for stage 2 hypertension—it is inadequate and delays control 2
• Never combine two RAS blockers (ACE inhibitor + ARB + renin inhibitor)—this is potentially harmful 1
• Never delay medication initiation while attempting lifestyle modifications alone in stage 2 hypertension—both must start immediately 1, 2
• Never use beta-blockers as first-line therapy unless there is a compelling indication (e.g., recent MI, heart failure, angina) 1, 6