How is elevated diastolic pressure managed?

Management of Elevated Diastolic Blood Pressure

Elevated diastolic blood pressure should be treated with a target of <80 mmHg for most patients through a combination of lifestyle modifications and pharmacological therapy, with medication selection based on patient characteristics and comorbidities. 1

Blood Pressure Targets

The most recent guidelines from the European Society of Cardiology (2024) recommend:

• Initial treatment goal: <140/90 mmHg for all hypertensive patients 1
• Optimal target: <130/80 mmHg for most patients if well tolerated 1
• Diastolic BP target: <80 mmHg for all hypertensive patients regardless of risk level and comorbidities 1
• For patients with systolic BP at target (120-129 mmHg) but diastolic BP ≥80 mmHg, consider intensifying treatment to achieve diastolic BP of 70-79 mmHg 1

First-Line Treatment: Lifestyle Modifications

All patients with elevated diastolic blood pressure should implement these lifestyle changes:

1. Dietary modifications:

   • Sodium restriction to approximately 2g per day (equivalent to 5g salt) 1
   • DASH or Mediterranean diet with increased consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids 1, 2
   • Low consumption of red meat and increased low-fat dairy products 1
   • Restrict free sugar consumption, especially sugar-sweetened beverages 1

2. Physical activity:

   • At least 150 minutes of moderate-intensity aerobic exercise weekly (or 75 minutes of vigorous exercise) 1, 3
   • Add resistance training 2-3 times weekly 1

3. Weight management:

   • Aim for healthy BMI (20-25 kg/m²) 1
   • Target healthy waist circumference (<94 cm in men, <80 cm in women) 1

4. Alcohol moderation:

   • Men: <14 units/week
   • Women: <8 units/week
   • Preferably avoid alcohol completely for best health outcomes 1

5. Smoking cessation for all tobacco users 1

Pharmacological Treatment

For patients with confirmed hypertension (BP ≥140/90 mmHg), medication therapy is recommended:

First-line medications:

• ACE inhibitors (e.g., lisinopril) 4
• Angiotensin receptor blockers (ARBs) (e.g., losartan) 5
• Calcium channel blockers (dihydropyridine type)
• Thiazide or thiazide-like diuretics 1, 6

Treatment algorithm:

1. Initial therapy: Combination therapy is recommended for most patients with confirmed hypertension 1

   • Preferred combination: RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or diuretic 1
   • For Black patients: Consider starting with CCB or thiazide diuretic 7

2. If BP remains uncontrolled:

   • Triple therapy: Add the third agent (typically a thiazide diuretic if not already included) 1

3. Resistant hypertension:

   • Add spironolactone (or eplerenone if spironolactone not tolerated) 1
   • Consider adding beta-blocker if not already indicated 1
   • Further options: centrally acting agents, alpha-blockers, hydralazine, or potassium-sparing diuretics 1

Special Considerations

Patients with diabetes:

• Target BP: <130/80 mmHg 1
• ACE inhibitors or ARBs are preferred first-line agents due to renal protection 1, 5
• Monitor renal function and potassium levels within 3 months of starting therapy and at least annually 1

Older patients (≥65 years):

• Target systolic BP: 130-139 mmHg 1
• Consider more lenient targets (<140 mmHg) for patients ≥85 years or with orthostatic hypotension 1
• For frail patients or those with limited life expectancy (<3 years), consider target <140/90 mmHg 1

Monitoring and Follow-up

• Regular BP monitoring at home and during office visits 7
• Follow-up every 3 months until BP is controlled, then every 6 months 7
• Monitor for medication adherence at each visit 7
• Check renal function, electrolytes, and urine albumin/creatinine ratio annually 1, 7

Common Pitfalls to Avoid

1. Over-reliance on medication: Studies show patients often depend on medication rather than adopting healthy lifestyle changes 8

2. Inadequate combination therapy: Most patients require multiple medications to achieve target BP 1, 6

3. Inappropriate combinations: Avoid dual RAAS blockade (ACE inhibitor + ARB) due to increased risk of hyperkalemia and renal dysfunction 7

4. Poor medication adherence: A major cause of treatment failure; assess at each visit 7

5. Insufficient lifestyle modification: Lifestyle changes can reduce BP by similar magnitudes as single antihypertensive medications and enhance pharmacological therapy 6, 9

By implementing this comprehensive approach to managing elevated diastolic blood pressure, patients can significantly reduce their risk of cardiovascular events, stroke, and mortality.