What is the initial treatment for diastolic hypertension?

Initial Treatment for Diastolic Hypertension

The initial treatment for diastolic hypertension should be a thiazide-type diuretic for most patients, which may be combined with lifestyle modifications including weight reduction, regular exercise, sodium restriction, and alcohol moderation. 1

Classification and Treatment Thresholds

Diastolic hypertension requires treatment based on the following thresholds:

• Diastolic BP ≥ 100 mmHg: Drug treatment should be started in all patients despite non-pharmacological measures 1
• Diastolic BP 90-99 mmHg: Treatment indicated if target organ damage is present, established cardiovascular disease, diabetes, or 10-year cardiovascular disease risk ≥ 20% 1
• Diastolic BP 80-89 mmHg: Classified as prehypertension; lifestyle modifications for 3-6 months before considering medication 1

First-Line Medication Options

When medication is indicated, the evidence supports:

1. Thiazide-type diuretics: First-line for most uncomplicated hypertension 1
2. ACE inhibitors: Particularly beneficial in patients with:
   • Heart failure
   • Left ventricular dysfunction
   • Type 1 diabetic nephropathy 1
3. Angiotensin II receptor blockers (ARBs): Alternative for ACE inhibitor-intolerant patients 1
4. Beta-blockers: Beneficial in patients with coronary heart disease 1

Treatment Algorithm

1. Stage 1 hypertension (140-159/90-99 mmHg):

   • Start with thiazide-type diuretic for most patients
   • Consider ACE inhibitor, ARB, beta-blocker, or calcium channel blocker based on compelling indications 1

2. Stage 2 hypertension (≥160/≥100 mmHg):

   • Begin with 2-drug combination (usually thiazide-type diuretic plus ACE inhibitor, ARB, beta-blocker, or calcium channel blocker) 1

3. Special populations:

   • Diabetes: Target BP < 130/80 mmHg; ACE inhibitors preferred as first-line agents 1
   • Renal impairment: Target BP < 130/80 mmHg 1
   • Established cardiovascular disease: Target BP < 130/80 mmHg 1

Lifestyle Modifications

Implement the following lifestyle changes regardless of medication status:

• Weight reduction: Achieve ideal body weight through reduced fat and calorie intake 1
• Physical exercise: Regular dynamic exercise (e.g., brisk walking) rather than isometric exercise 1
• Sodium restriction: Reduce salt in food preparation and eliminate excessively salty foods 1
• Alcohol limitation: < 21 units/week for men, < 14 units/week for women 1
• Dietary changes: Increase consumption of fruits and vegetables; consider DASH diet 2

Treatment Goals

• General population: Target BP ≤ 140/85 mmHg 1
• Diabetes, renal impairment, or established cardiovascular disease: Target BP ≤ 130/80 mmHg 1
• Minimum acceptable control (audit standard): < 150/90 mmHg 1

Important Considerations

• Systolic blood pressure is equally important as diastolic blood pressure for cardiovascular risk, especially in patients over 50 years 1
• Most patients will require two or more medications to achieve target blood pressure 1
• If blood pressure is >20/10 mmHg above goal, consider initiating therapy with two agents 1
• For diastolic dysfunction specifically, ACE inhibitors and ARBs have shown improvement in measures of diastolic function 3
• Monitor renal function and serum potassium levels when using ACE inhibitors or ARBs 1

By following this evidence-based approach, you can effectively manage diastolic hypertension and reduce the risk of cardiovascular morbidity and mortality.