From the Guidelines
For patients with elevated pulse pressure, the recommended initial treatment using anti-hypertensives is a combination of two drugs at low doses, with a preference for fixed combinations that simplify treatment schedules and favor compliance. This approach is supported by the 2007 guidelines for the management of arterial hypertension, which suggest that monotherapy is often insufficient to achieve target blood pressure in the majority of patients 1.
When selecting anti-hypertensive medications, several combinations have been found to be effective and well-tolerated, including:
- Thiazide diuretic and ACE inhibitor
- Thiazide diuretic and angiotensin receptor antagonist
- Calcium antagonist and ACE inhibitor
- Calcium antagonist and angiotensin receptor antagonist
- Calcium antagonist and thiazide diuretic
- β-blocker and calcium antagonist (dihydropiridine) 1.
In the context of elevated pulse pressure, calcium channel blockers (CCBs) and thiazide diuretics are generally recommended as first-line antihypertensive treatments, as they effectively reduce systolic blood pressure while having less effect on diastolic pressure, which helps narrow the pulse pressure. Treatment should be initiated at lower doses and gradually titrated based on response, with regular blood pressure monitoring to ensure that systolic pressure is reduced while maintaining adequate diastolic pressure. Lifestyle modifications, including sodium restriction, weight management, regular exercise, and limiting alcohol consumption, should accompany pharmacological treatment.
From the Research
Recommended Initial Treatment for Elevated Pulse Pressure
The recommended initial treatment for patients with elevated pulse pressure using anti-hypertensives is typically a thiazide diuretic, such as chlortalidone or hydrochlorothiazide 2.
Alternative Treatment Options
Alternative treatment options include:
- Angiotensin-converting enzyme (ACE) inhibitors, such as captopril, lisinopril, or ramipril, which can be used when a diuretic cannot be used 2
- Calcium channel blockers, which may be preferred in certain subsets of hypertensive patients, such as those with diabetes and nephropathy or with diminished left ventricular function 3
- Combination therapy with an ACE inhibitor and a calcium channel blocker, which can provide an additional antihypertensive effect and minimize the probability of adverse effects related to the dose of antihypertensive 4
Benefits of Specific Treatments
Specific treatments have been shown to have various benefits, including:
- Thiazide diuretics, which have been shown to reduce all-cause mortality and prevent stroke 2
- ACE inhibitors, which have been shown to reduce the incidence of stroke, reverse left ventricular hypertrophy, and improve congestive heart failure symptomatology and mortality 5
- Calcium channel blockers, which have been shown to reduce reinfarction in patients with ischemic heart disease and decrease congestive heart failure in patients with dilated cardiomyopathy 3
Considerations for Treatment
Considerations for treatment include:
- The patient's overall cardiovascular risk, with combination therapy indicated for patients with a higher risk 4
- The presence of target organ damage or kidney or cardiovascular disease, which may require more aggressive treatment 4
- The patient's individual response to treatment, with regular monitoring and adjustment of therapy as needed 2, 3, 4, 5