When do you treat hypertension (HTN)?

From the Guidelines

Hypertension should be treated when blood pressure consistently exceeds 130/80 mmHg, though treatment thresholds may vary based on individual risk factors. The most recent and highest quality study, 1, provides guidance on the diagnosis, evaluation, and treatment of hypertension. According to this study, hypertension is diagnosed when blood pressure is consistently ≥130 and/or ≥80 mm Hg.

Initial Management

Initial management includes lifestyle modifications such as:

• Reducing sodium intake
• Increasing physical activity
• Maintaining healthy weight
• Limiting alcohol
• Following a DASH diet

For stage 1 hypertension (130-139/80-89 mmHg) with low cardiovascular risk, lifestyle changes may be sufficient. However, for stage 1 hypertension with high cardiovascular risk or stage 2 hypertension (≥140/90 mmHg), medication is typically started.

Medication

First-line medications include:

• Thiazide diuretics (like hydrochlorothiazide 12.5-25 mg daily)
• ACE inhibitors (such as lisinopril 10-40 mg daily)
• ARBs (like losartan 25-100 mg daily)
• Calcium channel blockers (such as amlodipine 2.5-10 mg daily)

Treatment Goals

Treatment goals are generally <130/80 mmHg for most adults, though targets may be adjusted for elderly patients or those with comorbidities. Medication selection should consider the patient's age, race, comorbidities, and potential side effects. Regular blood pressure monitoring is essential to assess treatment efficacy, with adjustments made as needed to reach target values while minimizing side effects, as recommended by 1 and 1.

Special Considerations

It's worth noting that the study 1 breaks new ground with some of its recommendations, including the use of absolute cardiovascular risk to determine high-risk status and the initiation of drug therapy. Additionally, the study recommends that treatment should be initiated with two drugs having complementary mechanisms of action when blood pressure is >20/10 mm Hg above goal.

Overall, the management of hypertension requires a comprehensive approach that takes into account individual risk factors, lifestyle modifications, and medication therapy, as supported by the evidence from 1, 1, and 1.

From the FDA Drug Label

Losartan is indicated for the treatment of hypertension in adults and pediatric patients 6 years of age and older, to lower blood pressure. 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.

Treatment of Hypertension (HTN) should be initiated when:

• Blood pressure is elevated, as elevated systolic or diastolic pressure causes increased cardiovascular risk.
• The absolute risk increase per mmHg is greater at higher blood pressures, so even modest reductions of severe hypertension can provide substantial benefit.
• Patients are at higher risk independent of their hypertension, such as those with diabetes or hyperlipidemia, as they would be expected to benefit from more aggressive treatment to a lower blood pressure goal.

The decision to treat HTN should be based on 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) 2 3.

From the Research

Treatment of Hypertension (HTN)

• The treatment of hypertension (HTN) is guided by various factors, including the patient's blood pressure levels, presence of comorbidities, and risk of cardiovascular events 4, 5, 6, 7, 8.
• The American College of Cardiology (ACC)/American Heart Association (AHA) 2011 expert consensus document recommends reducing blood pressure to less than 140/90 mmHg in adults aged 60-79 years and to 140-145 mmHg if tolerated in adults aged 80 years and older 8.
• The European Society of Hypertension (ESH)/European Society of Cardiology (ESC) 2013 guidelines, the minority report from the 2013 Eighth Joint National Committee (JNC 8) guidelines, and other guidelines also support reducing blood pressure to less than 140/90 mmHg in adults aged 60-79 years 8.
• In adults aged 80 years and older, a blood pressure below 150/90 mmHg has been recommended, with a target goal of less than 140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease 8.

Blood Pressure Goals

• The optimal blood pressure goal for most patients with hypertension is less than 140/90 mmHg 4, 6, 7, 8.
• However, some studies suggest that lowering systolic blood pressure to 130-135 mmHg may be beneficial in patients with coronary heart disease or equivalent, or with diabetes 7.
• In patients with diabetic or nondiabetic nephropathy, including those with proteinuria, there is no convincing evidence that lowering systolic blood pressure below 130 mmHg provides additional benefits 7.
• In patients aged 70-80 years, current evidence suggests lowering systolic blood pressure to 135-145 mmHg, and in those above 80 years, to 145-155 mmHg 7.

Treatment Thresholds

• The current treatment threshold for hypertensive adults without diabetes or cardiovascular or renal disease is blood pressure above 160/100 mmHg or 160/90 mmHg, with some uncertainty over which diastolic threshold should be used 6.
• The first-choice treatment for hypertension in nondiabetic adults without cardiovascular or renal disease should be a thiazide diuretic, such as chlortalidone or hydrochlorothiazide 6.
• In patients who cannot tolerate a diuretic, an angiotensin-converting enzyme (ACE) inhibitor, such as captopril, lisinopril, or ramipril, may be considered as an alternative 6.