What is the recommended treatment for a patient with hypertension (blood pressure 159/94 mmHg)?

From the Guidelines

For a patient with hypertension (blood pressure 159/94 mmHg), the recommended treatment includes lifestyle modifications, but medication therapy is not immediately indicated unless there is evidence of cardiovascular disease or other target organ damage, or if the estimated 10-year risk of cardiovascular disease is ≥ 20% 1. The patient's blood pressure is close to the threshold for initiating antihypertensive drug therapy, which is sustained systolic blood pressure ≥ 160 mm Hg or sustained diastolic blood pressure ≥ 100 mm Hg 1. However, considering the latest guidelines, lifestyle modifications should be advised, including reducing sodium intake, adopting the DASH diet, regular physical activity, weight loss if overweight, limiting alcohol consumption, and smoking cessation. Some key points to consider in the management of this patient include:

• The optimal goals for blood pressure treatment are systolic blood pressure < 140 mm Hg and diastolic blood pressure < 85 mm Hg for non-diabetic people 1.
• The minimum acceptable level of control is < 150/ < 90 mm Hg 1.
• If medication is required, a first-line agent such as a thiazide diuretic, calcium channel blocker, or ACE inhibitor/ARB should be considered, with the specific choice depending on the patient's age, race, and comorbidities 1. The most recent guidelines from 2024 recommend reinforcement of lifestyle measures and consideration of additional therapies if blood pressure remains uncontrolled 1. It is essential to monitor the patient's blood pressure regularly and adjust the treatment plan as needed to achieve the desired blood pressure goals and reduce cardiovascular risk.

From the FDA Drug Label

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. Lowering blood pressure lowers the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see 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)

The recommended treatment for a patient with hypertension (blood pressure 159/94 mmHg) is to lower blood pressure using medications such as lisinopril 2.

• The goal is to reduce the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions.
• Lisinopril may be administered alone or with other antihypertensive agents.
• It is also important to follow 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), for specific advice on goals and management.
• Additionally, spironolactone 3 is also indicated for the treatment of hypertension, to lower blood pressure.

From the Research

Treatment Recommendations for Hypertension

The patient's blood pressure is 159/94 mmHg, which is considered hypertensive. According to the studies, the recommended treatment for hypertension is:

• A thiazide diuretic, such as chlorthalidone or hydrochlorothiazide, as the first-line treatment 4, 5
• The use of combinations of antihypertensive drugs as first-line therapy has not been evaluated in terms of the complications of hypertension, except for certain diuretic-based combinations 4
• Low-dose thiazide diuretics and angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce all-cause mortality in hypertensive patients 4

Comparison of Thiazide Diuretics

The studies compared the efficacy of different thiazide diuretics:

• Chlorthalidone was found to be more effective in lowering systolic blood pressure than hydrochlorothiazide 6
• Chlorthalidone was superior to the ACE inhibitor lisinopril in preventing stroke, and to the calcium-channel blocker amlodipine in preventing heart failure 4, 5

Additional Treatment Options

Other treatment options for resistant hypertension include:

• Aldosterone blockers, such as spironolactone or eplerenone, which can provide significant additional blood pressure reduction when added to multidrug regimens 7, 8
• The use of a triple regimen consisting of a thiazide diuretic, a calcium channel blocker, and an ACE inhibitor or angiotensin receptor blocker (ARB) may be effective and well-tolerated 7