What is the recommended treatment for a blood pressure of 131/91 mmHg, indicating elevated blood pressure (hypertension)?

Management of Blood Pressure 131/91 mmHg

For a blood pressure of 131/91 mmHg, initiate lifestyle modifications for 3 months, followed by pharmacological treatment if blood pressure remains ≥130/80 mmHg due to the increased cardiovascular risk associated with this level of hypertension. 1

Blood Pressure Classification and Risk Assessment

This blood pressure reading of 131/91 mmHg falls into the Stage 1 hypertension category according to current guidelines. At this level, there is an increased risk of cardiovascular disease, stroke, and other complications.

• The systolic reading (131 mmHg) exceeds the threshold of 130 mmHg
• The diastolic reading (91 mmHg) exceeds the threshold of 80 mmHg
• This combination indicates Stage 1 hypertension requiring intervention

Initial Management Approach

Lifestyle Modifications (First 3 Months)

Implement the following evidence-based lifestyle modifications immediately:

1. Dietary changes:

   • Follow the DASH diet (rich in fruits, vegetables, low-fat dairy) 2
   • Restrict sodium intake to <1500 mg/day 2
   • Increase potassium intake (3500-5000 mg/day) 2

2. Physical activity:

   • Engage in 90-150 minutes of moderate-intensity aerobic exercise per week 2, 3
   • Include both aerobic and resistance training

3. Weight management:

   • Target ideal body weight or weight loss of at least 1 kg if overweight/obese 2
   • Aim for BMI <25 kg/m² 4

4. Alcohol moderation:

   • Limit to ≤2 drinks per day for men (maximum 14/week) 2
   • Limit to ≤1 drink per day for women (maximum 9/week) 2
   • Preferably avoid alcohol consumption for optimal health outcomes 1

5. Reduce stress:

   • Implement stress management techniques 5

Pharmacological Treatment

If after 3 months of consistent lifestyle modifications, blood pressure remains ≥130/80 mmHg, initiate pharmacological treatment 1:

First-line Medication Options:

1. For non-Black patients:

   • Start with a RAS blocker (ACE inhibitor like lisinopril or ARB like losartan) 1, 6, 7
   • Consider combination with a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic 1

2. For Black patients:

   • Start with a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic 2
   • Consider ARB + dihydropyridine calcium channel blocker combination 2

3. Preferred initial combination therapy (if needed):

   • RAS blocker (ACE inhibitor or ARB) with either:
     • Dihydropyridine calcium channel blocker OR
     • Thiazide/thiazide-like diuretic 1
   • Fixed-dose single-pill combinations are recommended for better adherence 1

Blood Pressure Targets and Monitoring

• Target blood pressure: 120-129/70-79 mmHg 1
• Home blood pressure monitoring: Target <135/85 mmHg 2
• Monitoring schedule:
  • Monthly follow-up until blood pressure is controlled 2
  • Then every 3-6 months 2

Special Considerations

• Medication timing: Take medications at the most convenient time of day to establish a habitual pattern and improve adherence 1
• Avoid combining two RAS blockers (ACE inhibitor and ARB) as this is not recommended 1
• If blood pressure remains uncontrolled with a two-drug combination, increase to a three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic) 1

Pitfalls to Avoid

1. Therapeutic inertia: Don't delay adding pharmacological therapy if lifestyle changes are insufficient after 3 months 1
2. Inadequate dosing: Ensure medications are titrated to effective doses 1
3. Poor adherence: Use single-pill combinations when possible to improve compliance 1
4. Ignoring home readings: Home blood pressure monitoring provides valuable information about treatment efficacy 2
5. Overlooking secondary causes: Consider screening for secondary hypertension, especially in younger patients 1

Remember that hypertension management is a long-term commitment, and treatment should be maintained lifelong if well tolerated 1.