What are the implications and management of elevated blood pressure?

Management of Blood Pressure 128/88 mmHg

A blood pressure of 128/88 mmHg is classified as elevated blood pressure that requires lifestyle modifications, with pharmacological treatment consideration based on cardiovascular risk assessment. 1

Blood Pressure Classification

According to the 2024 ESC guidelines, a blood pressure reading of 128/88 mmHg falls into the "elevated blood pressure" category, defined as:

• Office BP: Systolic 120-139 mmHg or Diastolic 70-89 mmHg 1

This is distinct from:

• Non-elevated BP (<120/70 mmHg)
• Hypertension (≥140/90 mmHg)

Risk Assessment Approach

For patients with elevated BP, treatment decisions should be guided by cardiovascular risk assessment:

1. High-Risk Conditions - Immediate consideration for pharmacological treatment after 3 months of lifestyle modifications if any of these are present:

   • Established cardiovascular disease
   • Diabetes mellitus
   • Moderate or severe chronic kidney disease
   • Familial hypercholesterolaemia
   • Hypertension-mediated organ damage 1

2. 10-Year CVD Risk Assessment - Using SCORE2 (age 40-69) or SCORE2-OP (age ≥70):

   • ≥10% risk: Sufficient risk to warrant BP-lowering medication after 3 months of lifestyle changes
   • 5-10% risk with risk modifiers: Consider pharmacological treatment
   • <10% risk without modifiers: Lifestyle modifications only 1

3. Risk Modifiers to consider:

   • Sex-specific factors (pregnancy complications)
   • Ethnicity (e.g., South Asian)
   • Family history of premature CVD
   • Socioeconomic deprivation
   • Auto-immune inflammatory disorders
   • HIV
   • Severe mental illness 1

Management Algorithm

Step 1: Lifestyle Modifications (For All Patients)

• Physical activity: 150-300 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic exercise weekly, plus resistance training 2-3 times/week
• Diet: Increased consumption of vegetables, fruits, fish, nuts, unsaturated fatty acids; reduced red meat; low-fat dairy products
• Weight control: Target BMI 20-25 kg/m², waist circumference <94 cm (men) and <80 cm (women)
• Alcohol restriction: <14 units/week for men, <8 units/week for women (preferably avoid alcohol)
• Sodium reduction: Limit dietary sodium intake 1

Step 2: Risk-Based Decision for Pharmacological Treatment

• If high-risk conditions present OR 10-year CVD risk ≥10%: Initiate pharmacological treatment after 3 months if BP remains ≥130/80 mmHg despite lifestyle changes
• If moderate risk (5-10% with modifiers): Consider pharmacological treatment after 3 months if BP remains ≥130/80 mmHg
• If low risk (<10% without modifiers): Continue lifestyle modifications and monitor 1

Step 3: Pharmacological Treatment (If Indicated)

Initial therapy should include:

• Two-drug combination (preferably single pill): RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide/thiazide-like diuretic 1

Treatment Targets

If pharmacological treatment is initiated:

• Target BP: 120-129/70-79 mmHg for most patients
• For older patients (≥65 years): Target systolic BP 130-139 mmHg
• More lenient targets (e.g., <140/90 mmHg) for patients with:
  • Pre-treatment symptomatic orthostatic hypotension
  • Age ≥85 years
  • Moderate to severe frailty
  • Limited life expectancy (<3 years) 1

Monitoring Recommendations

• For those on lifestyle modifications only: Monitor BP and CVD risk yearly
• For those on pharmacological treatment: Monitor BP frequently (every 1-3 months) until controlled, then yearly 1

Important Caveats

• Confirm elevated BP with out-of-office measurements (HBPM or ABPM) or at least one additional office measurement before making treatment decisions 1
• Therapeutic inertia should be avoided - if BP targets are not achieved within 3 months, treatment should be intensified 1
• Single BP readings should not be used for diagnosis - multiple readings over time provide more accurate assessment 1
• The risk of cardiovascular events increases continuously with BP, even within the "elevated BP" range 2

By following this evidence-based approach, you can effectively manage patients with a BP of 128/88 mmHg to reduce their cardiovascular risk and improve outcomes.