What is the initial management for a newly diagnosed hypertensive adult, including lifestyle modifications and first‑line pharmacologic therapy for different ages, races, and comorbid conditions?

First-Line Hypertension Management

For newly diagnosed hypertensive adults, initiate lifestyle modifications immediately for all patients, and add pharmacologic therapy based on blood pressure stage and cardiovascular risk—specifically, start medication for stage 2 hypertension (≥140/90 mmHg) or stage 1 hypertension (130-139/80-89 mmHg) with existing cardiovascular disease or 10-year ASCVD risk ≥10%. 1

Blood Pressure Classification and Treatment Thresholds

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

• Lifestyle modifications alone for patients without existing CVD or 10-year ASCVD risk <10% 1
• Lifestyle modifications plus drug therapy for patients with existing CVD or 10-year ASCVD risk ≥10% 1
• Patients with diabetes mellitus or chronic kidney disease are automatically placed in the high-risk category requiring medication 1

Stage 2 Hypertension (≥140/90 mmHg)

• Initiate pharmacologic therapy promptly with lifestyle modifications 1
• For BP ≥160/100 mmHg, consider starting with two antihypertensive agents from different classes 1

Lifestyle Modifications (All Patients)

These interventions are the cornerstone of antihypertensive therapy and provide additive effects when combined. 1

Intervention	Expected BP Reduction	Specific Recommendation
Sodium restriction	5-10 mmHg systolic [2]	<2 g/day (approximately 5 g salt) [1]
Weight loss	5-20 mmHg per 10 kg [2]	Target BMI 18.5-24.9 kg/m² [3]
DASH diet	8-14 mmHg [2]	High in fruits, vegetables, low-fat dairy; low in saturated fat [1,3]
Physical activity	4-9 mmHg [2]	30-60 minutes aerobic exercise 4-7 days/week [1,3]
Alcohol moderation	2-4 mmHg [2]	≤2 drinks/day for men, ≤1 drink/day for women [3,4]
Tobacco cessation	Variable benefit [2]	Complete cessation mandatory [1]

• Concurrent use of two or more lifestyle interventions produces additive blood pressure reductions of 10-20 mmHg. 1

First-Line Pharmacologic Therapy

General Population (Non-Black, No Compelling Indications)

Start with one of the following four drug classes: 1, 4

1. Thiazide or thiazide-like diuretics (preferred: chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 25 mg daily) 4
2. ACE inhibitors (e.g., lisinopril 10-20 mg daily) 4
3. Angiotensin receptor blockers (ARBs) (e.g., losartan 50-100 mg daily) 4
4. Long-acting calcium channel blockers (e.g., amlodipine 5-10 mg daily) 4

Black Patients

• Preferred initial therapy: Thiazide diuretic or calcium channel blocker 3
• ACE inhibitors and ARBs are less effective as monotherapy in Black patients 3
• The combination of calcium channel blocker plus thiazide diuretic may be more effective than calcium channel blocker plus ACE inhibitor/ARB 5

Age-Specific Considerations

Patients <60 years:

• All four first-line drug classes are appropriate 3
• Beta-blockers may be considered in patients younger than 60 years 3

Patients ≥60 years:

• Thiazide diuretics and long-acting calcium channel blockers are preferred for isolated systolic hypertension 3
• Target systolic BP <130 mmHg if tolerated 1

Young adults with hypertension:

• Earlier onset of CVD events compared with normotensive peers 1
• Initial management with lifestyle modification for 6-12 months, followed by antihypertensive drug therapy if BP remains above goal 1

Compelling Indications for Specific Drug Classes

Comorbid Condition	First-Line Agent(s)	Rationale
Diabetes mellitus	ACE inhibitor or ARB [3,4]	Renal protection, cardiovascular benefit [3]
Chronic kidney disease	ACE inhibitor or ARB [3,4]	Slows progression of kidney disease [3]
Heart failure (HFrEF)	ACE inhibitor + beta-blocker [3]	Mortality reduction [3]
Post-myocardial infarction	Beta-blocker + ACE inhibitor [3]	Secondary prevention [3]
Angina	Beta-blocker or calcium channel blocker [3]	Symptom control [3]
Cerebrovascular disease	ACE inhibitor + diuretic [3]	Stroke prevention [3]

Blood Pressure Targets

• General target: <130/80 mmHg for most adults 1, 4
• Minimum acceptable: <140/90 mmHg 1
• Diabetes or chronic kidney disease: <130/80 mmHg 1, 3
• Older adults (≥65 years): Systolic <130 mmHg if tolerated 4

Monitoring and Follow-Up

Initial Assessment

• Confirm diagnosis with out-of-office BP readings (home BP monitoring ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg) to detect white coat hypertension 1
• Screen for secondary hypertension in patients with resistant hypertension, age <30 years with stage 2 hypertension, sudden onset or worsening of hypertension, or hypokalemia 1
• Assess for target organ damage (left ventricular hypertrophy, chronic kidney disease, retinopathy) 1

Medication Titration

• Reassess BP 2-4 weeks after initiating or adjusting therapy 1
• Goal: achieve target BP within 3 months of treatment initiation or modification 1
• For renin-angiotensin system inhibitors or diuretics, check electrolytes and renal function 2-4 weeks after initiation 1

Home Blood Pressure Monitoring

• HBPM is the most practical method to document BP for medication titration and maintenance of BP goal 1
• Enhances medication adherence and facilitates achievement of BP targets 1

Escalation to Combination Therapy

Most patients require more than one agent to achieve BP targets. 3, 4

When to Add a Second Agent

• If BP remains ≥140/90 mmHg after 4 weeks of optimal monotherapy 1
• For stage 2 hypertension (≥160/100 mmHg), consider starting with two agents immediately 1

Preferred Two-Drug Combinations

1. ACE inhibitor or ARB + calcium channel blocker 4
2. ACE inhibitor or ARB + thiazide diuretic 4
3. Calcium channel blocker + thiazide diuretic 4

Triple Therapy (If Needed)

• ACE inhibitor or ARB + calcium channel blocker + thiazide diuretic achieves control in >80% of patients 1

Critical Pitfalls to Avoid

• Do not combine ACE inhibitor with ARB (dual RAS blockade increases hyperkalemia and acute kidney injury without cardiovascular benefit) 1
• Do not use beta-blockers as first-line therapy unless compelling indication exists (they are less effective for stroke prevention than other first-line agents) 3
• Do not delay treatment intensification when BP remains above target—reassess within 2-4 weeks 1
• Do not assume treatment failure without first confirming medication adherence (non-adherence is the most common cause of apparent resistance) 1
• Intensive BP control does not increase orthostatic hypotension risk and should not be withheld based on this concern 1

Team-Based Care and Implementation Strategies

• Multilevel, multicomponent strategies including team-based care are the most effective methods for BP control 1
• Use fixed-dose single-pill combinations when possible to improve adherence 1
• Implement telehealth and telemonitoring to facilitate drug titration 1
• Screen for social determinants of health and barriers to care 1
• Provide clear, detailed, evidence-based care plans that ensure achievement of treatment goals 1