When to start antihypertensive (blood pressure lowering) medication in patients with hypertension?

From the Guidelines

Antihypertensive medication should be initiated at a blood pressure of 130/80 mmHg or higher in adults with diabetes, and the treatment goal should be less than 130/80 mmHg. For patients without diabetes, treatment should be initiated when blood pressure consistently exceeds 140/90 mmHg after a trial of lifestyle modifications, or immediately at levels above 160/100 mmHg 1. The decision to start antihypertensive treatment depends on blood pressure and total cardiovascular risk, with prompt initiation of pharmacological therapy recommended in high-risk patients or those with grade 3 hypertension 1.

Key Considerations

• First-line medications include thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers, with treatment individualized based on comorbidities 1.
• ACE inhibitors or ARBs are preferred for patients with diabetes or kidney disease, while beta-blockers are preferred for those with coronary artery disease.
• Home blood pressure monitoring is essential, with target readings below 135/85 mmHg (or 130/80 mmHg for high-risk patients) 1.
• Antihypertensives work through various mechanisms to reduce pressure on arterial walls and prevent end-organ damage to the heart, kidneys, and brain.

Treatment Approach

• Start with a low dose of a single medication and titrate upward every 2-4 weeks until target blood pressure is achieved.
• If one medication at maximum dose is insufficient, add a second drug from a different class.
• Consider initiating treatment if cardiovascular disease or other target organ damage is present, or if estimated 10-year risk of cardiovascular disease is ≥ 20% 1.

High-Risk Patients

• Patients with diabetes, chronic kidney disease, or cardiovascular disease require prompt initiation of antihypertensive treatment and closer monitoring to achieve target blood pressure goals 1.
• The goal for these patients is to achieve a blood pressure of less than 130/80 mmHg, with careful monitoring and adjustment of the treatment regimen as needed 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION 2. 1 Hypertension Initial Therapy in adults: The recommended initial dose is 10 mg once a day. 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.

When to Start Antihypertensive Medication:

• The decision to start antihypertensive medication should be based on the patient's blood pressure level and their individual risk factors for cardiovascular disease.
• Blood Pressure Goals: The goal of treatment is to lower blood pressure to a level that reduces the risk of cardiovascular events, such as strokes and myocardial infarctions.
• Initiation of Therapy: Therapy with lisinopril can be initiated at a dose of 10 mg once a day in adult patients with hypertension.
• Pediatric Patients: For pediatric patients with glomerular filtration rate > 30 mL/min/1.73m2, the recommended starting dose is 0.07 mg per kg once daily (up to 5 mg total) 2.
• It is essential to consider the patient's overall cardiovascular risk profile and to individualize treatment goals and strategies accordingly 2.

From the Research

Determining the Optimal Time to Start Antihypertensive Medication

• The decision to start antihypertensive medication in patients with hypertension depends on various factors, including blood pressure levels and the patient's overall cardiovascular risk 3, 4.
• According to the 2017 ACC-AHA Hypertension Guideline, antihypertensive drug therapy should be initiated based on blood pressure and an assessment of global cardiovascular disease risk 4.
• Lifestyle interventions, such as the DASH diet and behavioral weight management, can lower blood pressure and reduce the need for antihypertensive medication in some patients 4, 5.
• The American Heart Association recommends that patients with untreated stage 1 hypertension (systolic BP/diastolic BP, 130-139/80-89 mm Hg) with a 10-year risk for atherosclerotic cardiovascular disease <10% should first try lifestyle therapy for 6 months before considering medication 3.

Patient Groups that May Require Earlier Initiation of Antihypertensive Medication

• Patients with diabetes mellitus, target organ damage, or kidney or cardiovascular disease may require earlier initiation of antihypertensive medication 6.
• Patients with a high overall cardiovascular risk (SCORE ≥ 5%) may also benefit from earlier initiation of antihypertensive medication 6.
• Combination therapy with an ACE inhibitor and a calcium channel blocker may be an optimal choice for certain patient groups, including those with uncontrolled hypertension or cardiovascular risk factors 6, 7.

Importance of Individualized Treatment Decisions

• Treatment decisions should be individualized based on the patient's specific needs and circumstances 3, 4.
• Clinicians should consider the patient's blood pressure levels, cardiovascular risk factors, and other health conditions when determining the optimal time to start antihypertensive medication 3, 4.