What is the initial treatment for diastolic hypertension?

Initial Treatment for Diastolic Hypertension

Thiazide or thiazide-like diuretics are the recommended first-line pharmacological treatment for uncomplicated diastolic hypertension, with ACE inhibitors, ARBs, and calcium channel blockers as alternative first-line options. 1

Assessment and Classification

Diastolic hypertension is defined as diastolic blood pressure ≥90 mmHg. Treatment decisions depend on the stage of hypertension:

• Stage 1 hypertension: Diastolic BP 90-99 mmHg
• Stage 2 hypertension: Diastolic BP ≥100 mmHg 2

Treatment Algorithm

Step 1: Lifestyle Modifications

For all patients with elevated blood pressure, implement the following lifestyle modifications:

• Weight reduction: 5-20 mmHg reduction per 10 kg lost
• DASH diet: Rich in fruits, vegetables, low-fat dairy products; 8-14 mmHg reduction
• Sodium restriction: <2.3g daily; 2-8 mmHg reduction
• Regular physical activity: 30-45 minutes most days; 4-9 mmHg reduction
• Moderate alcohol consumption: ≤2 drinks/day for men, ≤1 drink/day for women; 2-4 mmHg reduction 1

These modifications can collectively reduce systolic BP by 10-20 mmHg in many patients.

Step 2: Pharmacological Treatment

For Stage 1 Hypertension (DBP 90-99 mmHg):

• Start with a thiazide-type diuretic for most patients
• Alternative first-line options include ACE inhibitors, ARBs, or calcium channel blockers 2, 1

For Stage 2 Hypertension (DBP ≥100 mmHg):

• Begin with a two-drug combination:
  • Thiazide-type diuretic + ACE inhibitor/ARB, or
  • Thiazide-type diuretic + calcium channel blocker, or
  • ACE inhibitor/ARB + calcium channel blocker 2, 1

Special Populations

Black Patients

• Thiazide diuretics or calcium channel blockers are preferred first-line agents 1

Patients with Diabetes

• ACE inhibitors or ARBs are preferred first-line agents
• Target blood pressure <130/80 mmHg 2, 1

Patients with Chronic Kidney Disease with Albuminuria

• ACE inhibitors or ARBs are recommended first-line 1

Elderly Patients (≥65 years)

• Same medication classes as younger patients
• Consider starting at lower doses
• Monitor for orthostatic hypotension 2

Monitoring and Follow-up

• For patients on ACE inhibitors, ARBs, or diuretics: Check serum creatinine/eGFR and potassium within 3 months of initiation, then at least annually 1
• Follow-up in 1 month for Stage 1 hypertension with drug therapy and Stage 2 hypertension
• Once BP is controlled, follow-up every 3-6 months 1

Target Blood Pressure

• For most adults: <130/80 mmHg 2
• For elderly patients: Systolic BP 120-129 mmHg if tolerated 2

Important Considerations

• Thiazide diuretics have the strongest evidence for cardiovascular outcomes in uncomplicated hypertension 1
• ACE inhibitors like lisinopril have demonstrated effectiveness in reducing diastolic blood pressure, with a recommended starting dose of 10 mg once daily, adjustable up to 40 mg daily 3
• Do not combine ACE inhibitors with ARBs as this increases adverse effects without additional benefit 1
• Multiple-drug therapy is often required to achieve blood pressure targets 2
• Diastolic dysfunction is present in approximately half of hypertensive patients and is associated with increased cardiovascular morbidity and mortality 4

By following this treatment algorithm, clinicians can effectively manage diastolic hypertension and reduce the risk of cardiovascular complications.