What is the management for elevated diastolic blood pressure?

From the Guidelines

For a patient with elevated diastolic blood pressure of 80/120mmHg, the most effective management strategy involves initiating lifestyle modifications, including weight loss, a DASH-style eating pattern, moderation of alcohol intake, and increased physical activity, as recommended by the most recent guidelines 1.

Key Lifestyle Modifications

• Weight loss when indicated
• Adoption of a DASH-style eating pattern, including reducing sodium intake to less than 2,300 mg/day and increasing potassium intake
• Moderation of alcohol intake, with no more than 2 servings per day in men and no more than 1 serving per day in women
• Increased physical activity, aiming for at least 150 minutes of moderate-intensity aerobic activity per week

Medication Therapy

If lifestyle modifications are insufficient to control blood pressure, medication therapy may be indicated, with first-line options including thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs, as suggested by earlier guidelines 1. However, the most recent and highest quality study 1 emphasizes the importance of lifestyle intervention as the initial approach.

Monitoring and Follow-Up

Regular blood pressure monitoring is essential to assess the efficacy of lifestyle modifications and medication therapy, with follow-up typically every 2-4 weeks until blood pressure is controlled, then every 3-6 months thereafter.

Priority on Lifestyle Modifications

Given the emphasis on lifestyle modifications in the most recent guidelines 1, it is crucial to prioritize these interventions as the first line of management for elevated diastolic blood pressure, with medication therapy considered only if lifestyle modifications are insufficient to achieve target blood pressure levels.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than one drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit

The management for elevated diastolic blood pressure, such as 80/120mmHg, involves comprehensive cardiovascular risk management. This includes:

• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake It is also recommended to follow published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), for specific advice on goals and management. Additionally, more than one drug may be required to achieve blood pressure goals 2 3.

From the Research

Management of Elevated Diastolic Blood Pressure

The management of elevated diastolic blood pressure, such as 80/120mmHg, involves a combination of lifestyle modifications and pharmacological interventions.

• The primary goal is to reduce blood pressure to a target level, which varies depending on individual factors such as age, comorbidities, and cardiovascular risk.
• According to 4, more than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents, either initially as combination therapy or as add-on therapy if monotherapy and lifestyle modifications do not achieve adequate blood pressure control.

Pharmacological Interventions

• Four main classes of medications are used in combination therapy for the treatment of hypertension: thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) 4.
• ACEIs and ARBs should not be used simultaneously 4.
• In black patients, at least one agent should be a thiazide diuretic or a calcium channel blocker 4.
• The combination of an ACE inhibitor and a calcium channel blocker is considered an optimal combination for the treatment of hypertension 5, 6.
• The fixed combination of perindopril and amlodipine has been shown to be effective in reducing cardiovascular events and improving blood pressure control 5, 6.

Treatment Guidelines

• The 2018 ESH/ESC guidelines recommend a fixed combination of a drug that blocks the renin-angiotensin-aldosterone system and a calcium antagonist or a diuretic as first-choice therapy in the majority of hypertensive patients 6.
• The choice of combination therapy should be individualized based on patient characteristics, such as the presence of diabetes, kidney disease, or cardiovascular disease 4, 7, 8.
• Current evidence suggests that the combination of a RAAS inhibitor with a CCB demonstrated the best efficacy in reducing cardiovascular endpoint, however, the combination of a RAAS inhibitor with a diuretic has shown beneficial results in particular subgroup of patients, such as patients with heart failure or with African American origin 8.