For a 28-year-old adult with uncomplicated primary hypertension and no comorbidities, which is preferred as first-line therapy: losartan (angiotensin‑II receptor blocker) or amlodipine (Norvasc, a dihydropyridine calcium‑channel blocker)?

First-Line Antihypertensive Choice for a 28-Year-Old with Uncomplicated Hypertension

For a 28-year-old with uncomplicated primary hypertension, either losartan or amlodipine (Norvasc) is equally acceptable as first-line therapy, with the choice determined by patient-specific factors rather than superiority of one agent over the other. 1, 2

Guideline-Based Equivalence

All major hypertension guidelines classify both ARBs (like losartan) and dihydropyridine calcium channel blockers (like amlodipine) as first-line antihypertensive agents with equivalent cardiovascular protection. 1, 2

• The 2022 WHO guideline provides a strong recommendation (high-quality evidence) for using thiazide diuretics, ACE inhibitors, ARBs, or long-acting dihydropyridine calcium channel blockers as initial treatment 1
• The 2017 ACC/AHA guideline similarly recommends thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs as first-line agents 1
• The 2024 ESC guideline reaffirms these four major drug classes as recommended first-line medications 1

Decision Algorithm: When to Choose Amlodipine

Select amlodipine (Norvasc) if the patient:

• Is Black/African American – Calcium channel blockers demonstrate superior efficacy to ARBs in preventing heart failure and stroke in Black patients without comorbidities 1, 2
• Requires predictable, dose-dependent blood pressure lowering – Amlodipine provides reliable 24-hour control with once-daily dosing across the 2.5–10 mg range 2
• Is elderly or frail – Start at 2.5 mg daily; amlodipine has demonstrated cardiovascular event reduction in older populations 2

Starting dose: 5 mg once daily (2.5 mg in elderly/frail patients); maximum 10 mg daily 1, 2

Decision Algorithm: When to Choose Losartan

Select losartan if the patient:

• Has albuminuria ≥300 mg/g creatinine – ARBs are strongly recommended (Class A evidence) to slow kidney disease progression 2
• Has established coronary artery disease – ARBs are preferred as first-line therapy 2
• Previously developed cough with ACE inhibitors – Losartan provides comparable renin-angiotensin blockade with markedly lower angioedema risk 2
• Is female or has venous insufficiency – Better tolerance profile regarding peripheral edema compared to amlodipine 2

Starting dose: 50 mg once daily; maximum 100 mg daily (though 50 mg is typically sufficient) 3

Blood Pressure Targets and Monitoring

Target blood pressure for this 28-year-old without comorbidities:

• Minimum target: <140/90 mmHg (strong recommendation, moderate-quality evidence) 1
• Optimal target: <130/80 mmHg (recommended by ACC/AHA for all patients) 1

Monitoring schedule:

• Reassess blood pressure 2–4 weeks after initiation 1, 2
• If target not achieved, increase to maximum dose or add second agent 1, 2
• Monthly follow-up after medication changes until target reached 1
• Every 3–5 months once controlled 1

When Monotherapy Fails

If blood pressure remains ≥140/90 mmHg after 4 weeks of optimized monotherapy, add a second agent rather than continuing dose escalation alone. 1, 2

The combination of losartan + amlodipine is specifically recommended by ACC/AHA guidelines:

• Provides complementary renin-angiotensin blockade and vasodilation 2, 4
• Reduces amlodipine-induced peripheral edema compared to amlodipine alone 2, 4
• Combining two drug classes provides approximately five times greater blood pressure reduction than doubling one drug 4

Critical Pitfalls to Avoid

Do not delay adding a second agent if blood pressure stays ≥140/90 mmHg after optimizing monotherapy – Combination therapy is more effective than further dose escalation 2

Confirm adherence and rule out white-coat hypertension (home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg) before assuming treatment failure 2

With losartan:

• Check serum creatinine/eGFR and potassium 2–4 weeks after initiation, then annually 2, 4
• Absolutely contraindicated in pregnancy; stop immediately if pregnancy detected 2, 4
• Use caution in bilateral renal artery stenosis (risk of acute renal failure) 2, 4

With amlodipine:

• Monitor for dose-related pedal edema, more common in women 2, 4
• Not first-line for heart failure with reduced ejection fraction 2, 4
• No routine laboratory monitoring required 2

Evidence Quality Note

The ALLHAT trial (large randomized outcome-based study) demonstrated amlodipine's safety and efficacy equivalent to chlorthalidone in preventing coronary heart disease mortality across all patient subgroups, providing Class I evidence 2. The LIFE study showed losartan reduced cardiovascular events 13% more than atenolol (primarily due to stroke reduction), though no head-to-head ARB versus diuretic outcome trial exists 1.