In stage 2 hypertension for a 52-year-old White British female with no other PMH, which antihypertensive is most appropriate to start?

• A. Amlodipine
• B. Lisinopril
• C. Ramipril
• D. Hydrochlorothiazide

Answer: (C)

The main idea here is choosing a first-line antihypertensive with proven ability to reduce cardiovascular risk in a patient with stage 2 hypertension and no other health issues. An ACE inhibitor like ramipril fits well because it lowers blood pressure and has strong evidence showing it reduces heart attack, stroke, and overall cardiovascular events in the general population. Ramipril also offers renal and vascular protective effects and is convenient to dose (often once daily), which supports good long-term adherence in a otherwise healthy middle-aged patient.

Other options are reasonable but come with trade-offs. Amlodipine, a calcium channel blocker, lowers BP effectively but can cause ankle edema and doesn’t provide the same renoprotective or long-term cardiovascular outcome data. A thiazide-type diuretic such as hydrochlorothiazide is effective and widely used, but it can disturb electrolytes and uric acid, which may be less desirable as a single starting therapy in an otherwise healthy individual. Lisinopril is another ACE inhibitor like ramipril, but ramipril has a longer-standing track record of cardiovascular outcome data in broad populations, which often guides its use as a robust starting option. If needed, therapy can be stepped up by adding a second agent from a different class to reach the target blood pressure.