Antihypertensive Medication Guidelines

First-Line Antihypertensive Medications

The American College of Cardiology recommends thiazide-type diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) as first-line antihypertensive medications, selected based on patient-specific factors and comorbidities 1, 2
Chlorthalidone (12.5-25 mg daily) is preferred over other thiazide diuretics due to its longer half-life and proven cardiovascular disease reduction in clinical trials 1, 2
ACE inhibitors, such as lisinopril (10-40 mg daily) and enalapril (5-40 mg daily), are particularly beneficial in patients with diabetes, left ventricular hypertrophy, heart failure, and chronic kidney disease 3, 4
ARBs, such as losartan (50-100 mg daily), are an alternative to ACE inhibitors in patients who develop cough 1
CCBs, such as amlodipine (2.5-10 mg daily), are effective and well-tolerated, particularly in Black patients and elderly patients with isolated systolic hypertension 2, 4

The American Heart Association recommends combination therapy with two agents of different classes for most patients with stage 2 hypertension (≥140/90 mmHg) 1, 2
Effective two-drug combinations include thiazide diuretic + ACE inhibitor, thiazide diuretic + ARB, CCB + ACE inhibitor, and CCB + ARB 6

In Black patients, initial therapy should include a thiazide-type diuretic or CCB, and combination therapy should include a diuretic and CCB 7, 4
In patients with diabetes, ACE inhibitors or ARBs are preferred, especially with albuminuria, while any of the four main drug classes can be used in patients without albuminuria 8, 9, 4
In patients with chronic kidney disease, ACE inhibitors or ARBs are preferred, particularly with albuminuria ≥300 mg/day, and target BP should be <130/80 mmHg 3, 4

Resistant hypertension is defined as BP ≥140/90 mmHg despite appropriate lifestyle management plus a diuretic and two other antihypertensive drugs at adequate doses 8, 9
Consider adding a mineralocorticoid receptor antagonist (e.g., spironolactone) for resistant hypertension 8, 9

Avoid simultaneous use of ACE inhibitors and ARBs, which increases adverse effects without additional benefit 1, 2
Beta-blockers are no longer considered first-line for uncomplicated hypertension due to reduced stroke prevention compared to other agents 6, 10