Initial Treatment Approach for Hypertension

Diagnosis and Lifestyle Modifications

The American Diabetes Association recommends beginning with lifestyle modifications as first-line therapy for 3-6 months before considering pharmacological treatment, unless blood pressure is severely elevated (≥140/90 mmHg), in which case add medication immediately alongside lifestyle changes 1, 2
Measure blood pressure at three separate visits using an appropriately sized cuff with the patient seated and relaxed 1
For adolescents ≥13 years, hypertension is defined as BP ≥130/80 mmHg or BP ≥95th percentile for age, sex, and height 1
Elevated blood pressure (prehypertension) is defined as BP 120-129/<80 mmHg or BP ≥90th percentile 1
Implement the DASH eating pattern emphasizing fruits and vegetables (8-10 servings/day) and low-fat dairy products (2-3 servings/day) 3, 2
Restrict sodium intake to <2,300 mg/day 2
Increase potassium intake through dietary sources 3, 2
Limit calories from fat to 25-30%, saturated fat to <7%, and avoid trans fats 1
Prescribe at least 150 minutes of moderate-intensity aerobic exercise per week 2
Limit alcohol to ≤2 drinks/day for men 2
Counsel on smoking cessation 2

For confirmed hypertension (≥140/90 mmHg), begin pharmacological treatment immediately in addition to lifestyle modifications 1
ACE inhibitors are the preferred initial agent (e.g., lisinopril 5-10 mg once daily) 1
Angiotensin receptor blockers (ARBs) are an alternative if ACE inhibitor is not tolerated 1
Thiazide-type diuretics or calcium channel blockers are additional first-line options 4
Provide reproductive counseling before prescribing ACE inhibitors or ARBs due to teratogenic effects 1, 2

Check serum creatinine and potassium 7-14 days after initiating ACE inhibitor or ARB 2
Monitor for hyperkalemia with ACE inhibitors/ARBs or hypokalemia with diuretics 2
Goal is BP <120/80 mmHg or <90th percentile for age, sex, and height 1, 2
The International Society of Hypertension recommends targeting systolic BP 120-129 mmHg for most adults if well tolerated 2
Reassess BP and medication tolerance within 2-4 weeks of initiation 2
Titrate medication or add additional agents if BP goals are not achieved 2