At what blood pressure reading should a patient be started on antihypertensive medication?

From the Guidelines

Antihypertensive medication should be initiated at a blood pressure of 130/80 mmHg or higher in adults with diabetes, and at a blood pressure of 140/90 mmHg or higher for most other adults, though treatment thresholds may vary based on individual risk factors. When considering the initiation of antihypertensive therapy, it's crucial to assess the patient's overall cardiovascular risk profile, rather than relying solely on blood pressure numbers. According to the 2017 American College of Cardiology/American Heart Association hypertension guideline 1, for patients with stage 2 hypertension, initiation of 2 antihypertensive agents from different classes is recommended when the average systolic blood pressure (SBP) and diastolic blood pressure (DBP) are more than 20 and 10 mm Hg above target, respectively.

Key considerations for initiating antihypertensive medication include:

• The patient's diabetes status, with a recommended treatment threshold of 130/80 mmHg or higher 1
• The presence of chronic kidney disease or cardiovascular disease, which may also warrant treatment at a blood pressure of 130/80 mmHg or higher
• The patient's overall cardiovascular risk profile, which should guide treatment decisions
• Lifestyle modifications, such as reducing sodium intake, increasing physical activity, maintaining a healthy weight, limiting alcohol, and following a DASH diet, which should be attempted before starting medication

Initial medication choices may include thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers, with the specific choice depending on the patient's individual characteristics and risk factors. It's also important to measure blood pressure accurately using proper technique and to confirm hypertension with multiple readings over several visits before initiating therapy. The British Hypertension Society guidelines from 2004 1 provide additional context, but the more recent and higher-quality evidence from the 2017 ACC/AHA guideline 1 takes precedence in guiding clinical decision-making.

From the Research

Blood Pressure Medication Guidelines

The decision to start a patient on blood pressure medication depends on various factors, including their blood pressure reading, presence of comorbidities, and overall cardiovascular risk.

• According to the Sixth Report from the Joint National Committee (JNC VI) 2, hypertensive persons with diabetes, renal disease, or heart failure should have goal BP levels lower than 130/85 mm Hg.
• For all other hypertensive individuals, the goal BP level should be minimally lower than 140/90 mm Hg 2.
• 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 the systolic blood pressure to 140 to 145 mmHg if tolerated in adults aged 80 years and older 3.

Special Considerations

Certain patient populations may require more aggressive blood pressure management:

• Patients with diabetes mellitus and renal insufficiency may benefit from tighter blood pressure control, with a goal BP of less than 130/80 mmHg 4, 5.
• Patients with advanced proteinuric chronic kidney disease (CKD) may require a BP goal of less than 130/80 mmHg to slow disease progression 5.
• Patients with a history of stroke or multiple risk factors for stroke may also benefit from a lower BP goal of less than 130/80 mmHg 5.

Initiating Treatment

Antihypertensive treatment should be started at a blood pressure level higher than 140-150/90 mmHg 4.

• The goal of treatment is to gradually lower blood pressure over several weeks to months to minimize the risk of treatment-related side effects 2.
• Lifestyle modifications, such as salt restriction and weight reduction, may be sufficient to lower blood pressure in patients with high normal blood pressure (130-139/85-89 mmHg) and a low cardiovascular risk profile 6.