A 42-year-old man presents for a follow-up visit for mild hypertension.

This patient requires antihypertensive therapy for persistent mild hypertension. He previously developed tongue swelling on ramipril , consistent with ACE inhibitor–induced angioedema , which is a contraindication to further ACE inhibitor use (e.g., enalapril). MCCQE objectives emphasize avoiding re-exposure to ACE inhibitors after angioedema due to risk of recurrence, which can be life-threatening.

Beta-blockers such as metoprolol are not first-line for uncomplicated hypertension and should be used cautiously in patients with asthma due to risk of bronchospasm (even though cardioselective agents are safer, alternatives are preferred). Clonidine and hydralazine are not first-line agents for chronic management due to side effects and rebound hypertension risk.

A thiazide diuretic (hydrochlorothiazide) is an appropriate first-line therapy for uncomplicated hypertension. Thiazides have strong evidence for cardiovascular risk reduction and are suitable in patients without contraindications.

Thus, hydrochlorothiazide is the most appropriate initial therapy in this patient.