What is the management of diastolic hypertension?

Management of Diastolic Hypertension

Diastolic hypertension should be managed with a combination of lifestyle modifications and pharmacological therapy, with treatment decisions based on diastolic blood pressure levels and cardiovascular risk factors. 1

Diagnosis and Classification

• Diastolic hypertension is diagnosed when diastolic blood pressure (DBP) ≥ 90 mmHg
• Classification based on diastolic BP levels:
  • 80-89 mmHg: Elevated (pre-hypertension)
  • 90-99 mmHg: Grade 1 (mild) hypertension
  • ≥100 mmHg: Grade 2 (moderate to severe) hypertension 2, 1

Initial Assessment

• Confirm elevated readings on multiple occasions
• Measure standing blood pressure in elderly patients and those with diabetes to assess for orthostatic hypotension 2
• Evaluate for target organ damage (heart, kidneys, eyes)
• Assess cardiovascular risk factors

Lifestyle Modifications (First-line for All Patients)

Lifestyle modifications should be implemented for all patients with diastolic hypertension:

• Weight reduction: Achieve ideal body weight; each kg lost can reduce BP by approximately 1 mmHg 1
• Dietary modifications:
  • Reduce sodium intake (<2300 mg/day)
  • Follow DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy)
  • Increase potassium intake 2, 1
• Physical activity: 150 minutes of moderate aerobic exercise weekly (can reduce systolic BP by 3-8 mmHg) 1
• Alcohol limitation:
  • Men: <21 units per week
  • Women: <14 units per week
  • Include alcohol-free days each week 2, 1
• Smoking cessation: Essential for overall cardiovascular risk reduction 1

The PREMIER clinical trial demonstrated that comprehensive lifestyle modifications can reduce diastolic BP by 3.7-4.3 mmHg compared to advice only 3.

Pharmacological Therapy

When to Initiate Drug Therapy

• Immediate initiation for diastolic BP ≥100 mmHg 2
• For diastolic BP 90-99 mmHg:
  • With target organ damage, diabetes, or high cardiovascular risk: Immediate drug therapy
  • Without risk factors: Trial of lifestyle modifications for 1-2 months, then add medications if BP remains elevated 2, 1

First-line Medication Options

1. ACE inhibitors (e.g., lisinopril) or ARBs: Particularly effective for diastolic hypertension; reduce morbidity and mortality 1, 4, 5
2. Calcium channel blockers (e.g., amlodipine): Effective BP reduction with proven cardiovascular benefits 1, 6
3. Thiazide or thiazide-like diuretics: Effective, especially in combination with other agents 1
4. Beta-blockers: Particularly in patients with coronary artery disease or heart failure 1

Medication Selection Algorithm

1. For non-black patients without compelling indications:

   • Start with ACE inhibitor/ARB 1

2. For black patients:

   • Start with calcium channel blocker or thiazide diuretic 1

3. For patients with specific comorbidities:

   • Diabetes: ACE inhibitor/ARB preferred 2, 1
   • Kidney disease: ACE inhibitor/ARB preferred 1
   • Heart failure: ACE inhibitor/ARB + beta-blocker 1
   • Coronary artery disease: Beta-blocker + ACE inhibitor/ARB 1

Titration and Combination Therapy

• Start with low doses and titrate upward if needed
• Most patients will require at least two medications to achieve target BP 2, 1
• If BP not controlled on three drugs (including a diuretic), consider adding spironolactone 1

Target Blood Pressure Goals

• General population: <140/90 mmHg 1
• Patients with diabetes, kidney disease, or established cardiovascular disease: <130/80 mmHg 2, 1
• Elderly patients (≥65 years): Individualize targets based on frailty; generally aim for <140/90 mmHg 1

Monitoring and Follow-up

• Follow-up every 2-4 weeks until BP goal is achieved, then every 3-6 months 1
• Monitor electrolytes, creatinine, and eGFR, particularly when using ACE inhibitors or ARBs 1
• Check electrolytes and renal function 1-2 weeks after initiating ACE inhibitors/ARBs 1
• Allow at least 4 weeks to observe full response to medication changes 1
• Encourage home blood pressure monitoring to guide medication adjustments 1

Common Pitfalls to Avoid

• Inadequate dosing: Ensure proper dose titration before adding new agents
• Ignoring adherence issues: Assess medication adherence at each visit
• Overlooking secondary causes: Consider secondary hypertension in resistant cases or young patients
• Neglecting lifestyle modifications: Continue to emphasize lifestyle changes even after starting medications
• White coat hypertension: Consider home or ambulatory BP monitoring to confirm diagnosis

Remember that most patients with diastolic hypertension will require multiple medications to achieve target blood pressure, and treatment should be tailored based on individual risk factors and comorbidities.