What is the treatment for diastolic hypertension?

Treatment of Diastolic Hypertension

The treatment of diastolic hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy with ACE inhibitors or ARBs as first-line agents when diastolic blood pressure remains ≥90 mmHg despite lifestyle changes or is initially ≥100 mmHg. 1, 2

Diagnosis and Targets

• Diastolic hypertension is defined as diastolic blood pressure ≥80 mmHg
• Blood pressure should be measured at every routine visit and confirmed on a separate day if elevated
• Treatment targets:
  • For most adults: <80 mmHg diastolic 1
  • For patients with diabetes or kidney disease: <80 mmHg diastolic 1, 2
  • For older adults (≥65 years): 70-79 mmHg diastolic if well tolerated 1

Treatment Algorithm

Step 1: Lifestyle Modifications (for all patients)

Implement the following lifestyle changes, which can reduce diastolic BP by 3-8 mmHg each:

• Weight reduction: Target BMI 20-25 kg/m² (1 mmHg reduction per kg lost) 2
• DASH diet: Increase fruits, vegetables, low-fat dairy; reduce saturated fats 1, 2
• Sodium restriction: 1200-2300 mg/day 1
• Physical activity: 150 minutes of moderate aerobic exercise weekly 1, 2
• Alcohol moderation: ≤14 units/week for men, ≤8 units/week for women 1, 2

For patients with diastolic BP 80-89 mmHg, try lifestyle modifications alone for up to 3 months before initiating pharmacotherapy 1.

Step 2: Pharmacological Therapy

Initiate drug therapy when:

• Diastolic BP ≥90 mmHg despite lifestyle modifications
• Initial diastolic BP ≥100 mmHg (start drugs immediately along with lifestyle changes) 1

First-line medications:

• ACE inhibitors (e.g., lisinopril) or ARBs (e.g., losartan) are particularly effective for diastolic hypertension 2, 3, 4
  • Lisinopril: Start with 10 mg daily, can increase to 20-40 mg daily 3
  • Losartan: Start with 50 mg daily, can increase to 100 mg daily 4

Second-line additions (if target BP not achieved with monotherapy):

1. Add a thiazide or thiazide-like diuretic (chlorthalidone preferred)
2. Add a calcium channel blocker (e.g., amlodipine 5-10 mg daily) 5

Third-line additions (if target BP not achieved with dual therapy):

• Add the remaining class from above that hasn't been used
• Most patients will require at least two medications to achieve target BP 2

Step 4: Resistant Hypertension

For patients not achieving target BP on three drugs including a diuretic:

• Add spironolactone or eplerenone 1
• If not tolerated, add a beta-blocker 1
• Consider referral to a hypertension specialist 1

Special Considerations

• Monitoring: Check electrolytes, creatinine, and eGFR within 1-2 weeks of initiating ACE inhibitors/ARBs 2
• Elderly patients: Lower blood pressure gradually to avoid complications 1
• Diabetes: ACE inhibitors or ARBs are strongly recommended as first-line agents 1
• Pregnancy: ACE inhibitors and ARBs are contraindicated; use methyldopa, labetalol, or nifedipine 2

Follow-up

• Allow at least 4 weeks to observe full response to medication changes 2
• Schedule follow-up visits every 2-4 weeks until BP goal is achieved, then every 3-6 months 2
• Consider home BP monitoring to guide medication adjustments 2

Remember that diastolic hypertension, especially when severe or prolonged, significantly increases cardiovascular risk. Prompt and effective treatment is essential to reduce morbidity and mortality from stroke, heart failure, and coronary artery disease 6.