What is the first-line management for a newly diagnosed adult with hypertension?

First-Line Hypertension Management

For newly diagnosed hypertension, initiate lifestyle modifications immediately in all patients, and add pharmacological therapy based on blood pressure stage: start single-agent therapy for Stage 1 hypertension (130-139/80-89 mmHg) with high cardiovascular risk (≥10% 10-year ASCVD risk), or start combination therapy with two agents from different classes for Stage 2 hypertension (≥140/90 mmHg). 1

Blood Pressure Classification and Treatment Thresholds

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

• Low cardiovascular risk (<10% 10-year ASCVD risk): Initiate lifestyle modifications alone and reassess in 3-6 months 1
• High cardiovascular risk (≥10% 10-year ASCVD risk, diabetes, or chronic kidney disease): Start single-agent pharmacotherapy plus lifestyle modifications immediately 1

Stage 2 Hypertension (≥140/90 mmHg)

• Start combination therapy with two antihypertensive agents from different classes plus lifestyle modifications at the first visit 1, 2
• For very high blood pressure (≥180/110 mmHg), initiate prompt treatment with close monitoring and rapid dose titration 1

First-Line Pharmacological Agents

Preferred Drug Classes

The following four drug classes have proven cardiovascular outcome benefits and should be used as first-line agents 1, 3:

1. Thiazide or thiazide-like diuretics (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide due to longer half-life and superior cardiovascular outcome data) 1, 2
2. ACE inhibitors (e.g., lisinopril 10-40 mg daily, enalapril 5-40 mg daily) 1
3. Angiotensin receptor blockers (ARBs) (e.g., losartan 50-100 mg daily, candesartan 8-32 mg daily) 1
4. Long-acting dihydropyridine calcium channel blockers (e.g., amlodipine 5-10 mg daily) 1

Recommended Two-Drug Combinations for Stage 2 Hypertension

• ACE inhibitor (or ARB) + calcium channel blocker 2, 4
• ACE inhibitor (or ARB) + thiazide/thiazide-like diuretic 2, 4
• Single-pill combination formulations should be used when available to improve adherence 1, 2

Lifestyle Modifications (All Patients)

Implement the following evidence-based interventions immediately 1, 3:

• Dietary sodium restriction to <1,500 mg/day (or at minimum <2,300 mg/day) 3
• Potassium supplementation to 3,500-5,000 mg/day through diet 3
• Weight loss targeting BMI 20-25 kg/m² (minimum 1 kg reduction provides benefit) 2, 3
• DASH or Mediterranean diet emphasizing fruits, vegetables, whole grains, low-fat dairy, and reduced saturated fat 2, 5, 3
• Physical activity of 90-150 minutes/week of moderate-intensity aerobic exercise plus resistance training 2-3 times/week 2, 3
• Alcohol limitation to ≤2 drinks/day for men and ≤1 drink/day for women 3

Blood Pressure Targets

• General target: <130/80 mmHg for adults <65 years; systolic <130 mmHg for adults ≥65 years 1, 3
• Patients with diabetes or chronic kidney disease: <130/80 mmHg 1, 2
• Patients with existing cardiovascular disease: Systolic <130 mmHg 1, 2
• Optimal target when tolerated: Systolic 120-129 mmHg 2

Follow-Up and Monitoring Schedule

• After initiating or changing therapy: Monthly follow-up until blood pressure target is achieved 1
• Check electrolytes and renal function 2-4 weeks after starting ACE inhibitor, ARB, or diuretic 1, 2
• Once controlled: Follow-up every 3-5 months 1
• Achieve blood pressure control within 3 months of initial diagnosis 2

Treatment Escalation Strategy

If blood pressure remains ≥140/90 mmHg after 1 month on two-drug combination therapy 2:

• Add a third agent from the remaining first-line classes (typically ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 2, 4
• Reassess adherence and optimize doses before adding additional agents 1

Critical Pitfalls to Avoid

• Never use monotherapy for Stage 2 hypertension – it is inadequate and delays blood pressure control 2
• Never combine two renin-angiotensin system blockers (ACE inhibitor + ARB + renin inhibitor) – this is potentially harmful 1, 2
• Never delay medication initiation while attempting lifestyle modifications alone in Stage 2 hypertension – both must start immediately 2
• Do not use beta-blockers as first-line agents unless compelling indications exist (recent MI, heart failure, angina) 2
• Avoid ACE inhibitors and ARBs in pregnancy or women planning pregnancy 1

Special Population Considerations

Patients with Diabetes

• Prioritize ACE inhibitor or ARB as one of the initial agents, especially if albuminuria is present 1, 4
• Target blood pressure <130/80 mmHg 1

Patients with Chronic Kidney Disease

• Include ACE inhibitor or ARB in the regimen, particularly if proteinuria is present 4
• Monitor serum creatinine and potassium closely 1

Black Patients

• At least one agent should be a thiazide diuretic or calcium channel blocker 4
• ARB preferred over ACE inhibitor if renin-angiotensin system blockade is needed 2

Older Adults (≥85 years) or Frail Patients

• Single-agent therapy may be considered instead of combination therapy 2
• Age alone does not justify monotherapy in otherwise healthy older adults with Stage 2 hypertension 2