What are the indications for initiating antihypertensive (blood pressure lowering) medication in patients with hypertension?

From the Guidelines

Antihypertensive medication is indicated for patients with blood pressure consistently at or above 140/90 mmHg, or for those with blood pressure above 130/80 mmHg who have additional cardiovascular risk factors such as diabetes, chronic kidney disease, or established cardiovascular disease. According to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1, treatment should also be considered for adults aged 65 or older with systolic blood pressure ≥130 mmHg.

Key Considerations

• First-line medication options include thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs, with the choice of initial medication considering the patient's comorbidities, potential side effects, and cost.
• For most patients with stage 2 hypertension (≥140/90 mmHg), combination therapy with two first-line agents from different classes is recommended from the outset 1.
• Treatment goals generally aim for blood pressure below 130/80 mmHg for most adults, though goals may be individualized based on age, frailty, and comorbidities.
• Lifestyle modifications including reduced sodium intake, increased physical activity, weight management, and limited alcohol consumption should accompany pharmacological treatment.

Rationale

The rationale behind these recommendations is based on evidence that earlier intervention reduces the long-term risk of cardiovascular events, stroke, and kidney disease associated with hypertension 1. While older guidelines such as the British Hypertension Society guidelines from 2004 1 suggested different thresholds for initiating treatment, the more recent and comprehensive guidelines from 2017 1 provide a clearer and more evidence-based approach to managing hypertension.

Clinical Application

In clinical practice, it is crucial to individualize treatment based on the patient's specific risk factors, comorbidities, and potential for adverse effects. Regular monitoring of blood pressure and adjustment of treatment as necessary are key components of effective hypertension management. By following these guidelines and considering the latest evidence, healthcare providers can help reduce the morbidity, mortality, and quality of life impacts associated with uncontrolled hypertension.

From the FDA Drug Label

INDICATIONS & USAGE 1. 1 Hypertension Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. Diuretics such as chlorthalidone are indicated in the management of hypertension either as the sole therapeutic agent or to enhance the effect of other antihypertensive drugs in the more severe forms of hypertension.

The indications to put a patient on antihypertensive medication are:

• Hypertension: to lower blood pressure in adult patients and pediatric patients 6 years of age and older.
• Severe forms of hypertension: to enhance the effect of other antihypertensive drugs. According to the drug labels 2 and 3.

From the Research

Indications for Antihypertensive Medication

The decision to put a patient on antihypertensive medication depends on various factors, including their blood pressure levels, presence of comorbidities, and risk of cardiovascular events. According to recent guidelines, the following are indications for antihypertensive medication:

• Patients with stage 1 hypertension (systolic blood pressure 130-139 mmHg or diastolic blood pressure 80-89 mmHg) who have a high risk of cardiovascular events, such as those with diabetes, chronic kidney disease, or a history of cardiovascular disease 4
• Patients with stage 2 hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) 4
• Patients with heart failure with reduced ejection fraction, who should be treated initially with a beta blocker and an ACEI or ARB (or an angiotensin receptor-neprilysin inhibitor), followed by add-on therapy with a mineralocorticoid receptor antagonist and a diuretic based on volume status 5
• Patients with chronic kidney disease and proteinuria, who should be treated with an ACEI or ARB plus a thiazide diuretic or a calcium channel blocker 5
• Patients with diabetes mellitus, who should be treated similarly to those without diabetes unless proteinuria is present, in which case combination therapy should include an ACEI or ARB 5

Choice of Antihypertensive Medication

The choice of antihypertensive medication depends on the patient's individual characteristics, such as their comorbidities and risk factors. According to recent studies:

• ACE inhibitors, calcium channel blockers, and diuretics are effective in lowering blood pressure and reducing the risk of cardiovascular events 6, 7, 8
• The combination of an ACE inhibitor and a calcium channel blocker may be a first-choice therapy for hypertension, as it has been shown to be effective in preventing myocardial infarction and total mortality 7
• Beta blockers may not be as effective as other classes of antihypertensive medications in lowering blood pressure and reducing the risk of cardiovascular events, especially in elderly patients 6