What medication is recommended for patients with diastolic hypotension and hypertension?

From the Guidelines

For patients with diastolic hypotension and hypertension, an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) should be considered as first-line treatment, alongside lifestyle modifications, to minimize the risk of micro- and macrovascular complications. When managing these patients, it's crucial to balance the control of systolic blood pressure with the potential risks of further lowering diastolic blood pressure. The goal is to target systolic blood pressure to less than 130 mmHg if tolerated, but not less than 120 mmHg, and to keep diastolic blood pressure below 80 mmHg but not less than 70 mmHg, as recommended by the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1. Key considerations include:

• The use of ACEIs or ARBs, which have been shown to reduce the risk of new-onset diabetes and are beneficial in patients with hypertension and diabetes 1.
• The importance of lifestyle changes, including guidance on diet, exercise, and weight management, to accompany medication therapy.
• The potential need for dual therapy, combining a RAAS blocker with a calcium channel blocker or diuretic, to achieve optimal blood pressure control 1.
• Regular monitoring of blood pressure and adjustment of treatment as necessary to minimize the risk of complications. In the context of real-life clinical practice, the choice of medication should prioritize the reduction of morbidity, mortality, and improvement of quality of life, taking into account the individual patient's profile and comorbidities. Given the most recent and highest quality evidence, the recommendation for patients with diastolic hypotension and hypertension is to initiate treatment with an ACEI or ARB, with careful monitoring and adjustment of therapy to achieve target blood pressure goals while minimizing risks 1.

From the Research

Medication Recommendations for Diastolic Hypotension and Hypertension

• For patients with diastolic hypotension and hypertension, the management of these conditions can be challenging due to the contrasting nature of the two conditions 2.
• Angiotensin receptor blockers and calcium channel blockers are suggested as preferable antihypertensives for these patients, as they may help manage hypertension without exacerbating diastolic hypotension 2.
• In cases of isolated supine hypertension, bedtime doses of short-acting antihypertensives can be considered 2.
• The removal of drugs that can worsen orthostatic hypotension, such as tamsulosin, tizanidine, sildenafil, trazodone, and carvedilol, is recommended 2.
• For the treatment of diastolic dysfunction in hypertension, angiotensin converting enzyme inhibitors and angiotensin receptor blockers have shown effectiveness in improving measures of diastolic function 3.
• Beta-blockers, calcium channel blockers, and diuretics may also be beneficial in improving indices of diastolic filling, although their independent impact on prognosis and outcome in diastolic dysfunction is not fully clarified 3.
• Fludrocortisone has been tested for the treatment of orthostatic hypotension and has shown some positive effects, such as improving systolic ophthalmic blood pressure on standing and reducing the fall of pulse volume 4.
• It is essential to be aware of drug-induced orthostatic hypotension, particularly in the elderly, and to maintain a high index of suspicion when prescribing drugs known to cause this condition, including alpha 1-blockers, adrenergic blockers, and centrally acting drugs 5.