Cardiovascular
Hypertension in adults: thresholds, first-line drugs and the pairings to avoid
The diagnostic numbers, the usual first-line classes, how comorbidity and race change the choice, and the combinations that are exam favorites.
10 min read·core·
Reviewed by a licensed nurse · 22 October 2026
Know which guideline the question is asking about
Hypertension is one of the most reliably tested topics, and the numbers depend on the guideline. The 2017 ACC/AHA guideline defines hypertension as 130/80 mmHg or higher. Some other guidelines, and older JNC 8 teaching, use 140/90 mmHg as the threshold to treat in many adults. Read the stem and the answer options for clues to which framework applies, and check the current exam content outline.
ACC/AHA blood pressure categories (adults)
| Category | Systolic | Diastolic |
|---|---|---|
| Normal | < 120 | and < 80 |
| Elevated | 120 to 129 | and < 80 |
| Stage 1 | 130 to 139 | or 80 to 89 |
| Stage 2 | 140 or higher | or 90 or higher |
Diagnosis is based on the average of two or more readings on two or more occasions. Home or ambulatory monitoring confirms it.
Choosing the first drug
- 01
Start from the usual first-line classes
Thiazide-type diuretics, ACE inhibitors, angiotensin receptor blockers and dihydropyridine calcium channel blockers.
- 02
Let comorbidity decide
Diabetes or chronic kidney disease with albuminuria: an ACE inhibitor or ARB. Heart failure with reduced ejection fraction: guideline-directed therapy, which includes an ACE inhibitor, ARB or ARNI, a beta blocker and others. Recent myocardial infarction: a beta blocker with an ACE inhibitor or ARB.
- 03
Adjust for race where the guideline does
In Black adults without heart failure or CKD, a thiazide-type diuretic or a calcium channel blocker is the usual first choice.
- 04
Check pregnancy and contraindications
ACE inhibitors and ARBs are contraindicated in pregnancy. Labetalol, nifedipine and methyldopa are commonly used. Look for angioedema history before an ACE inhibitor, and for hyperkalemia or bilateral renal artery stenosis.
- 05
Combine thoughtfully
If one drug is not enough, add a drug from a different class. Do not combine an ACE inhibitor with an ARB, and take care with an ACE inhibitor plus a potassium-sparing diuretic.
Adverse effects to match to the drug
- ·ACE inhibitors: dry cough, angioedema, hyperkalemia
- ·ARBs: hyperkalemia, angioedema (rare), no cough
- ·Thiazide-type diuretics: hypokalemia, hyponatremia, hyperuricemia, hyperglycemia
- ·Dihydropyridine calcium channel blockers: peripheral edema, flushing, headache
- ·Beta blockers: bradycardia, fatigue, may mask hypoglycemia
Check yourself
Did it stick?
1. A 58-year-old with type 2 diabetes and albuminuria has a blood pressure of 148/92 mmHg. Which agent is the best first choice?
2. Which combination should be avoided?
3. A pregnant patient has chronic hypertension and is taking lisinopril. What is the best action?
Sources
More in FNP certification
Educational content for exam preparation. It is not clinical guidance and does not replace your facility's policies, current professional guidelines or the advice of a qualified clinician.