Antihypertensive Therapy Selection

General Principles

• The American Heart Association recommends first-line antihypertensive medications to be selected from thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, or long-acting dihydropyridine CCBs based on patient characteristics and comorbidities 1, 3
• For most patients with confirmed hypertension, combination therapy is recommended as initial treatment, preferably as a single-pill combination to improve adherence 2
• Preferred combinations include a renin-angiotensin system (RAS) blocker with either a dihydropyridine CCB or thiazide/thiazide-like diuretic 2, 4
• Combining two RAS blockers is not recommended due to increased risk of adverse effects without additional benefit 2

Patient-Specific Considerations

• For Black patients, initial therapy should include a CCB or thiazide diuretic, as ACE inhibitors and ARBs are less effective as monotherapy in this population 4, 5, 6
• For non-Black patients, any of the four major drug classes can be used as initial therapy 3, 5
• For patients with diabetes, ACE inhibitors or ARBs are recommended first-line, providing renoprotection beyond BP lowering effects 1, 8
• For patients with chronic kidney disease and albuminuria, an ACE inhibitor or ARB is recommended as first-line therapy 8

Comorbidity-Based Selection

• For patients with coronary artery disease, ACE inhibitors or ARBs are suggested 8
• For patients with heart failure with reduced ejection fraction, ACE inhibitors or ARBs plus beta-blockers are recommended 2, 3

Severity-Based Approach

• For Stage 1 hypertension, single-agent therapy may be reasonable, especially in low-risk patients 4, 9
• For Stage 2 hypertension or BP >20/10 mmHg above target, initiate treatment with two first-line agents of different classes 4, 9

Stepped Care Approach

• If BP is not controlled with a two-drug combination, increase to a three-drug combination, preferably as a single-pill combination 2
• For patients not meeting BP targets on three classes of medications, consider adding a mineralocorticoid receptor antagonist 2, 8

Monitoring and Follow-up

• Monitor BP control monthly after initiation or change in medication until target is reached 1
• For patients on ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium at least annually 8
• Follow up every 3-5 months for patients with controlled BP 1